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Dream big, think little: the impact of the AHPBA

2021; Elsevier BV; Volume: 23; Linguagem: Inglês

10.1016/j.hpb.2021.08.815

1477-2574

Timothy M. Pawlik,

Pancreatic and Hepatic Oncology Research

The Hepato-Pancreato-Biliary Association (AHPBA) amazes me because of all the great people who make up our organization. I could pull any of your CVs and find an impressive list of achievements, but what I personally discovered during my time in the AHPBA is all of your remarkable energy, commitment and creativity. As you know, this past year we were limited to digital meetings and online encounters – yet all of you continued to show up and actively engage with our association. We quickly adapted with online webinars to discuss cases and share ideas. Our case-based webinars occurred routinely on a monthly or bi-monthly basis and covered a wide range of topics including: COVID-19 and HPB Surgery, controversies in transplant oncology, as well as surgical innovation and many other important subjects. I want to thank all those individuals who helped organize these events. The attendance at the webinars was incredible, frequently topping over 150–200 participants. It was so gratifying to see how these webinars allowed us to remain "together apart." We also continued to cultivate our outreach with "virtual chapter meetings" in Central and South America. While we would have preferred to be in person with our good colleagues from down South, the pandemic didn't decrease our enthusiasm – it only altered our approach. These "virtual chapter meetings" allowed us to stay connected with all of our members from these regions. I particularly want to thank Mariano Gimenez for his hard work ensuring that the relationships with our chapters and our colleagues in Central and South America stayed strong and remained a priority for the AHPBA during COVID19. I know that this year was not easy for any of us, yet I was so impressed by the resiliency, creativity and engagement of all of you. Because you showed up for the AHPBA, we were able to continue to improve in many important ways. All of you helped us make progress towards our mission – which is (and I'm quoting here), to "Advance HPB care to improve patient lives." That mission is the reason we do what we do – it's our "why". And while I know it seems like a pretty straightforward sentence, it packs a lot into just a few words – particularly three of those words…"improve patient lives." Think about how many layers of action that represents, and how each of us can serve that mission by lending our own unique talents and perspectives to AHPBA initiatives. When I started my own career, I had what I thought was a pretty similar "why." I wanted to become a surgical oncologist because cancer has touched my family. I wanted to do what I could to beat this terrible disease. That's a pretty good why – and it still motivates me today – but if my only why is to cure people with cancer…what happens on the days that I don't? I've since learned that medicine is not just a scorecard of supposed "wins" and losses" and we need to reframe our approach in order to offer patients hope to improve their lives. For me, being a surgeon is also about compassion, kindness and helping patients and their families live with a disease or transition from sickness to recovery or life to death. It's also about sharing knowledge, shouldering challenges together and teaching the next generation of surgeons. Equally important as my "why" is my "how." There's a physician adage to medical students that notes, "The next patient you see might be your 25th of the day, but always remember that you are their first doctor of the day." That's a powerful statement, and you could substitute the word "patient" in that sentence with student, or family member or colleague as well, depending on the interaction. Throughout my career, I've been blessed to have many individuals adopt a gracious attitude toward our relationship so I that could learn to become a better doctor, mentor, educator and person. Here at the AHPBA that includes so many of you. I've always looked for insight outside of medicine as well, to help me strengthen my resolve during difficult times without losing any measure of compassion or empathy, which I believe every great surgeon must have. One particularly inspiring person for me is Admiral Jim Stockdale, who was an American military officer. Stockdale was the highest ranking officer imprisoned in the "Hanoi Hilton," a brutal prisoner-of-war camp in Vietnam. During his eight-years of confinement, he was tortured over twenty times. He had no reason to expect release and no promise of ever seeing his family again. Yet he survived. How did he maintain faith that he would be released even as the years dragged on? Jim Collins – who wrote the bestseller, "From Good to Great" – gave the admiral's approach a name, "The Stockdale Paradox," and he argues that it is also the best way for other individuals and organizations to create positive change. The Stockdale Paradox is the concept that productive change begins when you accept the challenge you face, while also maintaining unwavering faith that you can and will prevail in the end, regardless of any difficulties. It's important to recognize that this unwavering faith is different than blind optimism, which can simply be a positive outlook without parameters. Instead, it's about finding an intensely pragmatic approach to resolving problems. So how can we apply the Stockdale Paradox as individuals? And how has the AHPBA already applied the principles of the Stockdale Paradox? One: by being honest. By admitting reality, even when it's difficult. Two: by finding a path forward based on that accepted starting point, always recognizing that it may not be easy, but it is possible. I'm convinced this is the best way to approach our careers and to help our patients prepare for and feel positive about their journey, even if it isn't the script they would have written for themselves. I also think the principles of the Stockdale Paradox helped the AHPBA tackle issues of Diversity, Equity and Inclusion this year. The reality is that the AHPBA is not as diverse an association as we want it to be and need it to be. We pinpointed our current reality and have embarked on a plan for long-term change. For years, organizations worldwide have discussed diversity, but I believe society is just now accepting the actual reality of its impact. I'm not a minority. I'm not underrepresented in medicine…and I most definitely do not have all – or even most – of the answers. Which is exactly why inviting more people under the tent and supporting their growth will better our Association, better our own knowledge and certainly better the care of our patients. Here at the AHPBA, the goal of our diversity initiatives has been to "align the AHPBA with policies to decrease inequities in healthcare and to rally members to advocate for diversity and inclusion within their own communities." And our purpose is – and I quote – "to condemn racial injustice and contribute to actionable change as healthcare leaders." Dr. Rebecca Minter during her year as President elevated the diversity conversation and helped us see the potential of the "Diversity bonus." To help us move forward over the past year, we held meetings, where leadership participated in a series of intentional conversations about implicit bias and racism with our Black AHPBA members. I want to thank Drs. Johnson, Clarke, Francis, and Lee. After listening to their experiences and becoming more informed about the challenges faced by underrepresented minorities in our Association, we made an organization-wide pledge to become part of the solution to address systemic racism and discrimination. As such, this year we established the Diversity, Equity and Inclusion Committee, chaired by Dr. Clarke to help us develop, implement and sustain strategies that will improve education, training, mentorship and recruitment within our URM ranks. The newly established DEI Committee has already made progress by: creating educational programs, partnering with the Research Committee to advance racial disparities research, promoting Women in HPB Surgery, and focusing on grassroots efforts to increase diversity and representation in HPB Surgery. We also issued public statements following the murders of George Floyd, Breonna Taylor, Ahmaud Arbery and countless other victims of discrimination and injustice, to call for change and an end to racial discrimination. Importantly, the AHPBA and AHPB Foundation also joined together to establish a travel grant for URM trainees, so they can spend one week visiting a qualified HPB Surgery Program to train with an established AHPBA member. This valuable program will give URM trainees early exposure to mentorship and networking to advance their HPB surgery career, as well as their involvement in our association. And to support further inclusivity, the AHPB Foundation has also made a commitment to appoint a URM member and a URM non-member to its Board. I thank Dr. Callery and the board for these efforts. I want to strongly encourage all of you to attend the DEI "Call to Action" session here at the meeting. I, along with many others from many different institutions will be discussing why DEI initiatives matter and how these efforts have changed our own home organizations for the better. For example, at Ohio State, we recognized the shortcomings that result from not having enough women in roles of surgical leadership. And, in turn, we established the Olga Jonasson Professorship in Surgery to recognize, encourage and enable female surgeons to realize their professional and research goals. I am proud that Dr. Carrie Sims, our Trauma Division Chief, is the inaugural recipient of this honor. As surgeons we should all be aware of Dr. Jonasson's legacy. Olga Jonasson was a renowned transplant surgeon who became the first woman in the United States to lead an academic surgery department when she was named chair of Ohio State's Department of Surgery in 1987. In the 34 years since her appointment, there have been just 34 other female chairs of surgery nationwide – 24 currently – so we are making progress…or at least incremental progress. We need to remain purposeful, however, with our strategic DEI efforts to continue to transform culture and build stronger more diverse teams, which will drive innovation, discovery and improved patient care. To this point, we established a No "MANEL" Policy at the AHPBA meeting this year. I want to thank – perhaps ironically – a man for helping make this happen. Dr. Ajay Maker and the program committee did a fantastic job putting together a meeting that is top-notch and inclusive, providing proof yet again that efforts to increase excellence and diversity is a "both/and" proposition, rather than an "either/or" fallacy. Of course, men are still allowed to participate – we're just not allowed to dominate. Our hope is that by ending MANELS, the AHPBA will foster more inclusive thinking and actions. It should also help us uncover our own personal blind spots, decrease "mansplaining" and promote a wider range of opinions and life perspectives that will enrich our meetings. Later today we will be celebrating and discussing the important role that women play in HPB surgery and the AHPBA. Please be sure to join our HPB Heroines for what I know will be an outstanding session here at the meeting. Like all of you, I believe we are obligated as both medical professionals and a community to address disparities, and to help move our organization to use its collective voice to foster more DEI awareness. We must remain vigilant and we must continue to be purposeful and strategic in our approach to diversity, equity, and inclusion as an Association. Our hope is that by serving as an example to other influential healthcare organizations, they too will join the AHPBA in this charge and adopt similar initiatives to eliminate inequities in medicine. Of course, I know that the continual push for change can be difficult. But I also think this is one of the strengths of the AHPBA and HPB surgeons – we always look for and in fact enjoy the tough surgical case, the difficult situation, the hard task. As HPB surgeons we look for ways to stretch ourselves and we don't back down from challenges. Ryan Holiday's book, "The Obstacle is the Way," highlights this point and emphasizes that when you consider every obstacle an opportunity to get better, grow stronger and become tougher yourself, there's only potential upside. Something about you and those around you can improve through every situation. The book draws its inspiration from stoicism, the ancient Greek philosophy of enduring pain or adversity with perseverance and resilience. Stoics focus on the things they can control, let go of everything else, and turn every new obstacle into an opportunity to get better, stronger, tougher. As Marcus Aurelius put it nearly 2000 years ago: "The impediment to action advances action. What stands in the way becomes the way." Holiday distinguishes between proactive people – those who focus on what they can do and influence – from reactive people who waste energy on things beyond their control. He also describes what he calls the Circle of Concern and the Circle of Influence – and this concept has personally helped me prioritize where I want to spend my time. The Circle of Concern includes the whole range of things that keep you up night – world hunger, global warming, politics, the fact that your favorite show on Netflix was not renewed. Our lists are all going to be different, yet our realities are the same: things in our Circle of Concern are not always – and frequently are not at all - within our ability to change. This can make your circle of concern paralyzing. You can worry about these things, but many items can't be changed just because you want them changed. On the other hand, our Circles of Influence are much smaller, yet this is where our power lies – it includes those things that we CAN change. If we focus on our efforts here, we can drive change and have impact as effective leaders. In contrast, if we spend all of our energy trying to fix things within our Circles of Concern where we don't always have control, then our Circles of Influence will shrink. We will drain our energy, and be perceived as ineffective and negative, no matter how hard we work. Leaders have a responsibility to have a positive impact on their circle of influence. Part of this responsibility is to be – as Admiral Stockdale noted - realistic, yet eternally optimistic. Anyone can complain. Anyone can find problems. Leaders provide an inspirational vision, as well as practical tools and solutions to move the team forward. One of my leadership heroes is Earnest Schackleton. Shackleton's skills as a leader were demonstrated during the Endurance expedition, when his leadership was crucial in saving the lives of all 28-members of the crew after his ship was crushed by ice at the South Pole in 1914. Shackleton was an inspiration, instilling a belief that the marooned men would survive and all of them did! Incredibly, the crew endured almost two years of the most unbearable conditions at the end of earth – much worse than any surgical residency or fellowship – and never lost their faith in each other. Even though his expedition, judged by its initial objectives, was a colossal failure because his ship, the Endurance, never reached Antarctica, Shackelton can serve as a role model. As often noted, leaders are defined by times of crisis. Shackleton kept his crew focused on the future. The ship was gone; previous plans were irrelevant. Now the goal was to bring the team home safely, and he improvised, adapted and used every resource at hand to achieve the safe return of his crew. As such, we can all learn from Shackleton's experience. In particular Dr. Amy Climer has highlighted five take-home leadership messages:1.Model and Inspire Optimism: Shackleton believed in his mission and in his team. His optimism was contagious. He intentionally made decisions to inspire optimism in his crew.2.Develop a Clear, Shared Purpose: Everyone who joined the Antarctic Expedition understood the purpose. They were selected, in part, for their interest and excitement in that purpose. Clarity around purpose has been shown, time and again, to be the most important factor to impact a team's success.3.Build Unity and Commitment Within the Team: Shackleton valued hard-work and loyalty above all else. Yet, he didn't expect this automatically; he intentionally fostered it. The team's well-being was his top priority, higher than his mission. He knew without the team, they could never reach their goal.4.Create a Plan, an Alternate Plan, and Be Flexible: After the team left Patience Camp they traveled in three life boats searching for land, which they hadn't seen in 15 months. During the 15 day journey, Shackleton changed the plan four times. Leaders need to always be open to new information and adjust to meet the end goal.5.Make the Tough Decisions: Shackleton continually made difficult decisions throughout the expedition. For instance, when the ship arrived in Argentina after crossing the Atlantic, the cook got drunk and disorderly one night. He was fired. Shackleton knew that man was not a good fit for his team. He then hired a new cook who proved to be an excellent addition. I firmly believe that the AHPBA has an important role in empowering our members to expand their circle of influence, learn how to turn obstacles into opportunities and grow as leaders …in essence, we have a duty to identify and cultivate the future Shackletons of our Association. To move towards this goal, as well as broaden our circle of future AHPBA leaders, this year we established the AHPBA Leadership Academy. This is a new leadership and mentorship opportunity for AHPBA members within the first 5–7 years of practice who want to pursue an AHPBA leadership pathway. Our inaugural Academy class of 6 AHPBA members was selected from an open call for candidates. The Academy members attend leadership committee meetings, attend our Executive Council and AHPB Foundation meetings, as well as participate in routine seminars with AHPBA leaders and outside invited guests to discuss topics such as finances, team building, strategy, marketing, and other core skills needed to be successful future leaders of our Association. With this initiative, the AHPBA is purposefully creating a pipeline of capable, diverse young members who will be well positioned to lead our organization in the future. I am equally excited about the creation of our Junior Surgeon Committee. The objective of this new committee is to support the integration of surgeons-in-training, as well as faculty within the first 5 years of practice, into the AHPBA. I would like to thank Tim Vreeland and Tim Newhook for their efforts in establishing this committee. The committee will facilitate collegiality, collaboration, and mentorship, as well as help us develop leadership programs for junior HPB surgeons who will play critical roles in the future of our Association. Specifically, this committee is charged with organizing early-career webinars, workshops that focus on the early years in HPB practice, as well as establishing a junior surgeon's toolkit. No matter if you are a junior surgeon, a senior surgeon, nurse practitioner, advanced practice provider, fellow, resident, or medical student – never underestimate the potential of your impact. As Robert Quinn has noted, effective change leaders understand a profound but elusive lesson: transformative change begins on the inside. If we want to positively influence others we need to do what we are afraid to do. We have to have the courage to put the collective good ahead of our ego needs. Doing so is the essence of leadership. As we strive to be a positive influence on others and our Association, we must find the courage to be positive deviants, to do good things that are outside the conventional culture. Research has shown that the departure from expected behavior can have incredible, far-reaching, and positive effects. Outliers often succeed against all the odds, figuring out problems that others are unable – or perhaps unwilling to even try to solve. Malcolm Gladwell popularized this concept of outliers in his book by that name. Gladwell asks the question: what makes high-achievers different? You've probably have heard of the 10,000 hour rule, which was popularized by Gladwell in this book. As Gladwell tells it, the rule goes like this: it takes 10,000 hours of intensive practice to achieve mastery of complex skills. Many of you in this audience are masters – master surgeons, master clinicians, master educators, master researchers, master administrators……others of us are still on our journey towards mastery. Yet we all need to ask ourselves – where will I focus my 10,000 hours, what will I seek to master and how will I use these skills to drive change. I encourage all of you to look for places where you can have an impact – because we each have unique talents that can transform not only the AHBPA, but also our individual medical centers, departments, families, neighborhoods, and certainly the lives of our patients. Gladwell asks us to reframe the way we think about the world ….to look beyond our intuition and concentrate our resources on a few key areas. After all, "… The world may seem like an immovable, implacable place. It is not. With the slightest push – in just the right place – it can be tipped." The key is finding the right place that matches your master talents so that you can have the biggest impact on the most people. I hope you will seek out those potential tipping points through your participation in the AHPBA. How can you reimagine the way you participate with the AHPBA – or perhaps in the lives of your family, colleagues and patients – so that you focus on the biggest and most impactful priorities. How can you – and how can I – unleash our full potential to serve the AHPBA in our stated collective goal to "Advance HPB Care to Improve Patient Lives". To date, the AHBPA has accomplished so much. Whether it be the growth of our chapters in Central and South America that was first envisioned by Nic Vauthey and Mark Callery, the humanitarian outreach efforts driven by Garzi Zibari, the ultrasound courses lead by Ellen Hagopian that have trained hundreds of our members, the amazing education opportunities for our fellows promoted by Rohan Jeyarajah and Tara Kent, the patient education initiatives championed by Felipe Coimbra, or the refresh of our strategic plan lead by Chuck Vollmer ….the AHPBA has achieved an incredible amount and has had an impact spanning all of HPB surgery throughout North and South America. As I step aside as a leader in the AHPBA, I am more excited and encouraged than ever about the future of our association. The future is bright and the possibilities are limitless. As Ishtiaq Khan noted, we are a product of what we think. Every process starts or emerges first from thinking. Thinking is the ignition that starts us. Thinking is the fuel that put us on a path. Thinking is what leads us forward and gives us the ability to choose a path. Now on which path we put ourselves, which direction we move our life …..that all depends on our thinking. If we think BIG – then possibilities open up – our mind will be able to find ways to greatness. As such, I challenge myself and I challenge all of you – for the betterment of HPB surgery and our patients – let's continue to push each other to THINK BIG about what the AHPBA will choose to tackle next. What will be our Association's priorities? What will be the way AHPBA continues to have maximal impact? I look forward to seeing the future that the AHPBA helps create to push the frontiers of HPB education, research, clinical delivery, and patient care. It will be amazing! Thank you for allowing me the honor to serve as the AHPBA President this past year. I appreciate everyone's support, partnership and – most importantly – your friendship. So I leave you with sincere gratitude and one last piece of advice: Dream Big ….Think Little…… find your purpose, define your circle of influence, hone your leadership skills ….and let's continue to make a difference and have a lasting impact on HPB surgery for the betterment of each other and our patients. Thank you!! I would like to thank Amy Skidmore, Marjie Malia, and Jill Willhite for their critical contributions, review, and revisions.