Responsibility
2015; Lippincott Williams & Wilkins; Volume: 78; Issue: 4 Linguagem: Inglês
10.1097/ta.0000000000000569
ISSN2163-0763
Autores Tópico(s)Health and Medical Research Impacts
ResumoI would like to thank you for allowing me this opportunity to serve as president of our Association. It is a singular honor for which I am immensely grateful. Each of us has had role models, mentors, and friends who have helped us to attain our success in surgery. I have been fortunate to have many. As a student, I met Drs. Gamelli and Davis, who not only showed me that surgery was the correct specialty for me but also then went on to provide the framework for my training in residency and support for my academic career. I am immensely grateful to each of them. After completing residency, I was assigned to the Institute of Surgical Research or the US Army Burn Unit to fulfill my Army obligation. There, I was fortunate to work with and for Drs. A.D. Mason and Basil A. Pruitt. The support I received from each of these individuals clinically, academically, and personally can never be repaid. Upon leaving San Antonio, I was recruited to Brown University. During the past two decades I have worked with a large number of faculty, residents, and students who helped transform a small community trauma service into a well-run academically active and clinically excellent division. I would like to thank my vice-chair of surgery and longtime friend, Dr. Tom Tracy; Dr. David Harrington, who serves not only as our program director but also the director of our Burn Center; and Dr. Chuck Adams, our division chief. All three are colleagues but more importantly friends. The entire Division of Trauma deserve the most thanks for it is they who do the lion's share of clinical work and research. The past year has been one of both personal, and I hope, Association growth. The Executive Committee, Drs. Scalea, Coimbra, Croce, Briggs, and Mackersie, deserve special thanks, as does the entire the Board of Managers. I have been fortunate to have many friends in our Association over the 25 years that I have been a member. I would like to personally thank Drs. David Feliciano, Jerry Jurkovich, L.D. Britt, Ron Maier, and Wayne Meredith for their support and guidance. I would be remiss if I did not thank the person who helps drive the mission of the AAST [American Association for the Surgery of Trauma] and who I believe has been instrumental in helping our Association grow during the past decade, Ms. Sharon Gaustchy, our executive director, and her staff, Ms. Jermica Smith and Ms. Tamara Jenkins, who play a pivotal role in helping us advance our core mission. I come from a family with four brothers and sisters who remain close friends and continuous supporters of each of our families. My parents were instrumental in helping me realize my goals, with my father teaching me motivation and discipline and my mother, caring and empathy, all traits which I hope I have carried over into my professional and personal life. My wife Theresa and our five children are the people who sacrificed most for my professional career and deserve special thanks. For decades, Theresa has taught me compassion, caring, and perspective, and our children, Jessica, Rachel, Sara, Nicholas, and Isabel constantly provide me with the continued motivation to attempt to maintain a balanced perspective. I love them all dearly and thank them for their patience and support. When trying to decide on a topic for my address, I went through the usual path of reading scores of presidential addresses and talking to many friends all whose comments were very similar—talk about something you care for, make it personal, and be passionate about it. After months of thought, panic set in when I realized the meeting was only a few months away, and I had yet to decide on a topic. In reality, I chose the title "Responsibility" last year. I chose "Responsibility," not because of the large number of issues facing health care such as cost, a perceived decline in quality, the public's perception of medicine and physicians, the future of trauma, or the decline in real NIH [National Institutes of Health] funding, but because I believe it is our responsibility to advance our Association and profession forward during these tumultuous times. Our mission statement for the AAST is to serve as the premiere scholarly organization for surgeons dedicated to the field of trauma and the care of critically ill surgery patients. The AAST is dedicated to discovery, dissemination, implementation, and evaluation of knowledge related to acute care surgery by fostering research, education, and professional development in an environment of fellowship and collegiality (Fig. 1).Figure 1: Mission of the American Association for the Surgery of Trauma.In 2008, President Jerry Jurkovich initiated a process of redefining and rebranding our Association.1 The perception of the AAST brand by members and nonmembers alike provided the infrastructure for a strategic planning process initiated by Past President Mackersie. This strategic planning process that you have heard about in detail fully supported the concept of the AAST being the preeminent trauma organization in the United States and the world and allowed us to focus our current efforts in three areas: (1) our Journal, the vessel from which we disseminate our knowledge; (2) acute care surgery, the future of our clinical endeavors; and (3) research and scholarship, an area critically important to the advancement of the care of our patients. With this in mind, I would like to focus my comments on our responsibility on five principles on which our profession was built and our organization founded; they are scholarship, mentorship, integrity, service, and leadership. Each is essential if we are to succeed in our mission. Scholarship or academic study and achievement has been a requirement for membership in our Association since it was founded 75 years ago. Many of the seminal contributions to the care of the injured patient have been made by our members and presented at our annual meeting. Our members and the Association have been leaders in basic, translational, and clinical research, the findings of which undoubtedly have benefited thousands and thousands of patients. However, despite our success, we are now faced with a multitude of problems and issues involving the quality of our work and the funding available to pursue our research. NIH funding, which has declined in real dollars during the past decade, has become increasingly more difficult to obtain. Research support from industry likewise has decreased. However, despite these issues, other specialties have been more successful in obtaining and maintaining federal dollars for research in their areas of interest. These include the American Burn Association and the neurosurgical and orthopedic communities, all who have obtained millions of dollars for trauma-related research. We in the general trauma community have not been as successful. The quality of our surgical research has also been questioned. In 1996, an article in Lancet entitled "Surgical Research or Comic Opera—Questions but Few Answers" was published.2 The authors reviewed the first issue of nine general surgical journals specifically looking at the type of research and the quality of the product. Of the 215 articles, 175 were original research. Of the 175, only 12 or 7% reported a randomized controlled trial, 31 or 18% reported on animal or basic science research, while 80 or 46% reported on case series. Obviously case series are cheaper, quicker, and easier to perform and may generate valuable data, of which hypotheses may be framed for future research but suffer from the weakness of their evidence and, more importantly, the lack of follow-up on the findings. The fact that only 8% of our research involves randomized controlled trials is troublesome, but the quality of these trials has also been questioned. Balasubramanian et al.3 reviewed 69 randomized controlled trials, and the structure of those in the surgical arena was much worse than those in medicine. Jacquier et al.4 reviewed 158 articles reporting a randomized control trial in surgery and stated that many of them suffered from significant defects. Only 7% described the setting of the trial, 3% provider volume, and 41% selection criteria for providers or participants. The failure to provide this type of data and other data brings into question the findings of either a negative or a positive trial. Shikata et al.5 reviewed the concept that large case studies may be just as good as randomized controlled trial as many surgeons believe that they are just as valuable as a randomized controlled trial. He reported that 25% of observational studies gave results different from those of a randomized controlled trial on the same subject, calling into the question the validity of large-volume case studies. Further is the issue of negative trials. In 2008, Brody et al.6 reviewed 54 influential randomized controlled trials in surgey. Thirty-two of the 54 trials showed a difference between groups. However, of the remaining 22 negative studies, only 7 were adequately powered, while 15 had inadequate numbers to draw a conclusion that the groups were not different. Six of these 15 either inadequately or wrongly interpreted their results, leading to erroneous conclusions. Comparison with other specialties overall indicates that we are no better or worse, but to me, it is clear that we can do better. Part of our problem is trying to figure out how to study things such as pelvic packing and fixation, rib fracture plating, or even the appropriate volume and components of large-scale damage-control resuscitation. How does one take an idea such as pelvic packing or rib fracture plating from an observation to an appropriately designed trial, demonstrating potential efficacy and benefit to long-term data collection allowing for review of quality assurance. During the past decade, a framework for the investigation for surgical innovation has been suggested and has been termed the IDEAL methodology, that is, Idea, Development, Exploration, Assessment, Long-term monitoring.7 IDEAL describes a method for structured study ranging from proof of concept to safety and efficacy and comparative effectiveness. The use of such a framework would allow for careful study and appropriate data interpretation. In Stage 1, the question is merely, can a procedure or device achieve a specific physical or physiologic goal. Only a few patients are required for proof of concept. In Stage 2, a prospective development study would allow for the evaluation of safety and efficacy in consideration for what is the optimal technique or design and for which patients does the procedure or treatment work best. This too only requires a small number of patients, allowing sufficient data to form a prospective collaborative observational study or a feasibility control trial that would evaluate the outcomes of more widespread use and whether consensus equipoise can be reached on a trial question. If so, the idea can be advanced to study how well the procedure or device works compared with current standards of care in a randomized controlled trial to study comparative effectiveness. If indeed the procedure or device is superior to current standards, then studying the long-term effects and outcomes of the procedure at the formation of a comprehensive disease or procedure-based registry will allow for the evaluation of long-term quality assurance (Fig. 2).Figure 2: IDEAL framework.Why are this concept and the potential control of trials necessary? There are many examples in the literature of how the acceptance and proliferation of procedures has gone awry, whether it is in the area of robotics, gastric banding, angel chick prostheses, appropriate resuscitation for trauma patients, or other scenarios. The problem is that the dollars available to perform such a study in the trauma population are severely lacking. For instance, this past year, NIGMS [National Institute of General Medical Sciences] awarded only one new P50 Award for translational research in the field of trauma. Our strategic planning process of last year outlined that we must put significant effort into the area of scholarship and research if we are to move our research agenda forward. Toward this end, the AAST convened a collaborative meeting between our Association, the National Trauma Institute, EAST [Eastern Association for the Surgery of Trauma], Western Trauma Association, The American Trauma Society, and the Committee on Trauma to form a coalition that would not only set the research agenda for the future but also lobby effectively for more federal dollars for trauma-related research as our colleagues in burns, orthopedics, and neurosurgery have successfully accomplished. The first meeting allowed each group to educate the others on past and current success and their vision for the future. In addition, representatives from the burn, orthopedic, and neurosurgery communities shared their successes and failures. This has led to the formation of the Coalition for National Trauma Research or CNTR that will be driven from leadership of our Association, the National Trauma Institute (NTI), and our fellow trauma organizations (Fig. 3A). With monetary investments from AAST and NTI, five discrete areas have been identified to enhance the potential for success of garnering of federal dollars for trauma research (Fig. 3B). One is to redefine the research agenda for trauma in 2014. What are the questions that need to be answered, and how should they be prioritized. Second is the formation of a clinical trials coalition, allowing for the performance of either large observational trials or randomized controlled trials. Third is the formation of a committee to guide the development of a trauma research data registry for which the NTI has already garnered a $5 million DOD [Department of Defense] contract. Fourth is the formation a Federal Relations Committee with representatives from NTI and AAST who will meet and work with representatives from the NIH and DOD in an effort to arrive at mutually beneficial relationships. Finally is the concept of a trauma lobby day, a yearly event in which trauma providers from around the country will meet with members of the Congress to educate them on the importance of this concept and garner their support for enhanced funding. Efforts like this were instrumental in our orthopedic and burn colleagues' success in garnering federal research dollars. These efforts must include monetary investment for external lobby support. Although it is obviously too early to judge potential success of this coalition, the formation of such a group with one voice should enhance our chances for success.Figure 3: (A) CNTR members. (B) CNTR mission.MENTORSHIP The term mentor is defined as an experienced and trusted advisor, and the concept of mentorship is ancient. The word mentor was derived from Homer's The Odyssey where Mentor was the tutor to whom Ulysses entrusted his son Telemachus.8 Because Ulysses was absent for more than 20 years, Mentor was responsible not only for the education of Telemachus but also for shaping his character, wisdom, and his sense of purpose. The importance of mentors and role models is highlighted in several publications dealing with the selection of career choices by medical students and surgical residents. In the mid-90s, Ko et al.9 reported that it was the impression of senior faculty that the most common reasons residents chose a surgical specialty was a particular role model or mentor. Claude Organ, in his 1998 Presidential Address to the Pacific Coast Surgical Society said, "We are role models, if we make academic surgery attractive, future generations will regard academic surgery as a profession worth seeking."10 One could easily substitute acute care surgery and reach the same conclusions. In 1999, I performed a survey of surgical residents in which I sought to determine the major factors they considered in choosing a career.11 This survey sent to 1,000 chief residents and a select group of junior residents was quite revealing. The single most important factor in choosing a surgical specialty was the presence or absence of role models in their training program in a specific area of expertise. Encouraging was the fact that 80% of residents thought that there were good clinical role models in their department. However, it was somewhat discouraging that only 55% and 38%, respectively, thought that they were both good academic and research role models in their department. In a study of medical student choices of surgical careers, motivation by role models was one of the primary reasons that medical students chose a specialty as reported by Erzurum et al.12 In some instances, the influence of a role model exceeded intellectual challenge, excitement, fascination with surgical work, and decisive intervention as the primary reason for choosing surgery. In a book entitled The Seasons of a Man's Life, Levinson described not only how a mentor or role model may benefit a protégé but also how there are also tangible benefits in this relationship for the mentor.13 Levinson referred to mentoring as the essence of adulthood. This concept was first suggested by Rogers in 1958 when he said, "The degree to which I could create relationships which facilitate the growth of others as separate persons is a measure of the growth I have achieved myself."14 The benefits of successful mentoring to our specialty should be clear, but what about each of us individually? Dalton et al.15 described a four-stage model when they were attempting to analyze the stages of professional career and development (Fig. 4). The original data on 2,500 engineers found a negative correlation after the age of 35 years between age and performance rating. This was first interpreted that the most productive years for an engineer were before the age of 35 years. However, when they looked at the data more closely, there was a cohort of older engineers who not only were as highly valued as younger engineers but also received performance ratings that were as high as or higher than their colleagues. They next collected data from interviews of 550 professionally trained scientists, engineers, accountants, and professors. Using their four-stage model, moving from apprentice to colleague to mentor to sponsor allowed them to reevaluate their earlier data. What was clear is that not every individual moved through the four stages of professional development. What was more important however was for those individuals older than 40 years, the relationship between stage and performance level was quite clear. Individuals older than 40 years who did not advance at least into Stage 3, which was concerned with mentorship, received uniformly poor performance ratings compared with colleagues in Stages 3 and 4. Thus, it would seem that success in one's career and avoidance of professional stagnation almost demand that we accept our role as mentors and role models and accept greater levels of responsibility.Figure 4: Four stage model of career development adapted from Dalton et al.15Each of us sitting in this room can think not only of several people whom we considered to be our mentors and role models throughout our early careers but also of someone who epitomizes this concept. However, precise definition of the perfect mentor or role model is difficult. As we consider our role as a mentor, it may be helpful to look at the various aspects and attributes of good mentors and mentoring. Jerimiah Barondess in his presidential address to the American Clinical and Climatological Association characterized the various aspects of mentoring into those that were explicit and those that were implicit.16 The explicit aspects of mentoring were those of a teacher or advisor, career counseling, clinical guidance, and technical expertise. It is easy to understand how much of our surgical training is characterized by such explicit efforts. However, those things that he described as implicit are as important or maybe even more important in our role as mentors. These include intellectual style, professional priorities, sense of fairness, truth telling, deliberateness, as well as respect and affection for the sick. These attributes that are not conscientiously or deliberately displayed to our students truly define professionalism (Fig. 5).Figure 5: Characteristics of good mentorship.For me, and in my career, I was fortunate to have a mentor and role model who I believe is the epitome of a mentor and fulfilled all aspects that I have described. Dr. Basil Pruitt has served as my mentor, teacher, colleague, and most importantly, friend for almost three decades. His untiring efforts in behalf of those who worked with him and for him should serve as an example for all of us as we are entrusted with the development of the next generation of acute care surgeons. The rebound in interest in our specialty, as indexed by the increase in applicants for surgical critical care fellowships and the intense interest in our acute care surgery fellowships, to me, indicates that during the past decade, we have demonstrated to surgical trainees the professional and personal benefits of our specialty. More recent data concerning the importance of mentorship comes from a survey of almost 2,700 young surgeons of whom 12% described themselves as a trauma surgeon.17 Thirty-seven percent of respondents believe that educational and mentorship programs geared to medical students would improve interest in surgery and membership in surgical organizations. Our student program has been an outstanding success but remains underfunded. I encourage you to consider investing in our 20-for-20 program, so that we may expand exposure to our meeting and the Association to our students. One of the most poignant examples of the importance of mentoring is described in an article by Daniel Hall from the University of Pittsburgh entitled "The Guild of Surgeons as a Tradition of Moral Enquiry."18 In this article, the author reports correspondence between a young trauma surgeon recently deployed to Afghanistan and his trauma mentors back home. The author states: "It is clear that these men care for their trainee having invested nearly 10 years of their own lives into his training. They speak as if to their son who is precisely what Jim has become through his training under their discipline. Surgeons must often act independently, but they are far from independent. They are dependent on those who have taught them their art. Surgeons are fond of saying that they stand on the shoulders of giants who taught them or their teachers. Surgeons come to trust that regardless of the time of day or night, they are only one phone call away from the mentors who train them and continue to support their practice." This unique description of surgical mentoring should serve to reinforce in each of us our responsibility in this area. Indeed, this practice is so important that it is included in the Fellowship Pledge of the American College of Surgeons in which, "Upon my honor, I declare that I would advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities, in turn I will willing help my colleagues when requested." INTEGRITY In a scene from one of my favorite sports movies, Bobby Jones was playing in the first round of the 1925 US Open at the Worchester Country Club near Boston. His approach shot to the eleventh hole's elevated green fell short into deep rough on the embankment. As he took his stance to play the ball, the head of his club brushed the grass and caused a slight movement of his ball. He hit his shot but then informed his playing partner, Walter Hagan, and the USGA official covering the match that he was calling a penalty on himself. After the round and before he signed his score card, officials argued with Jones, but he insisted that he had violated Rule 18, moving a ball at rest after address and took a 77 instead of a 76 that he would have carded. Jones' self-imposed one stroke penalty eventually cost him the win by a stroke in regulation that necessitated a playoff that he then lost. Although he was praised by many for his integrity, Jones was reported to have said "You might as well praise me for not robbing banks." A similar event occurred in the next US Open, where once again Jones called a penalty on himself, but this time went on to win the second of his four US Open victories. Integrity as characterized by Jones' actions is defined as the quality of being honest and having strong moral principles, the state of being whole and undivided. Integrity is a concept of consistency of actions, values, expectations, and outcomes. Integrity is a personal choice that is uncompromising and a particularly consistent commitment to honor moral and ethical principles. In ethics, integrity is regarded by many people as the honesty and truthfulness or accuracy of one's actions and stands in opposition to hypocrisy. Simply stated, integrity may be defined as "doing the right thing." The concept of integrity may be extended in a business or group context in which the integrity of a group is regarded by some as seeking to maintain a consistent unambiguous position in the mind of their audience. This includes consistent messaging and sense of purpose. So why am I talking about integrity? What does it have to do with the AAST and our responsibility to do the right thing? Not long ago, as described in Jerry Jurkovich's 2008 Presidential Address, the ASST and the identity of our profession, trauma, was to some of our members "near extinction," "gasping for air," "undervalued."1 These thoughts and many others concerning the future of trauma surgery led to our identity and branding effort. Jurkovich described brand and identity as a mixture of tangible and intangible attributes, images, and associations that people have in their minds about a particular organization, which helps distinguish one organization from another. The goal of our branding activity was to examine who we were as a professional organization and specialty and how we could better position ourselves to adapt, survive, and thrive in a time of rapid evolution in medicine. This led to the identification of three of the greatest challenges facing the membership of the AAST: the economics of health care, the recruitment and retentions of surgeons willing and able to take emergency call, and the visibility and credibility of trauma surgeons. It was clear that the AAST was positioned as a leader in the field of trauma and was viewed as the premiere organization of thought leaders in academic trauma surgery. Jurkovich went on to describe that the anxiety surrounding our specialty revolved around our identity or lack thereof. A significant amount of time and energy was spent outlining all that was wrong with trauma as a specialty and a lifestyle. The primary factors driving disaffection for trauma as a specialty included its increasingly nonoperative nature, the requirement for in-house night call, the perception that it was a lifestyle unfriendly, and other negative attributes. It is no wonder that at that time, there was a declining interest in trauma, as it seemed so many trauma surgeons were unhappy and not the best role models. Solutions focused on improving our lifestyle and professional satisfaction floundered. Early attempts to define a new identity for trauma surgery that focused on us rather than our patients were ill advised and unsuccessful. Past President Frank Lewis in his role as Executive Director of the American Board of Surgery helped refocus our efforts and thoughts on designing a new specialty, which would first and foremost serve the needs of our patients and, secondarily, offer an attractive and viable sustainable career and lifestyle with a solid foundation of operative experience. This refocusing of effort to fulfill a societal need rather than a personal need resulted in a model built on the foundation of general surgery that would combine trauma, surgical critical care, and emergency surgery. Later termed acute care surgery by Past President Britt, we developed a training paradigm and curriculum and began the process of verifying training fellowships. In 5 short years, we now have 17 verified fellowships, some of which have been visited for a second time, Maintenance of Certification questions and examinations, a case-log system for our trainees, and an almost completed new curriculum. The true success of our creation of the acute care surgery model however is in the recognition of the fulfillment of a true societal need. Gale et al.19 recently published a review of a 10-year analysis of the nationwide inpatient data sample from 2001 to 2010. They specifically focused on emergency general surgery and noted that over that decade, 7.1% of all hospital admissions were for emergency general surgery diagnoses and more than one fourth of those required an operation. During the 10 years of study, admissions increased by 28%, operations by 32%, and sepsis cases by 15%. Interestingly, mortality and length of stay both decreased over the decade. They concluded that the emergency general surgery burden of disease is substantial and increasing, that the annual case rate is higher than the sum of all new cancer diagnoses, and that the public health implications still remain largely unstudied. The answer to the question—"if we build it, will they come?"—I think has been generated. Now, instead of debating whether the specialty should exist or is needed, recent publications focus on improvement in care afforded by this new specialty and rightful considerations for the regionalization of emergency general surgery or acute care surgery patients similar to that which was achieved for trauma patients decades ago. The success of our new specialty has been recognized from afar as well. In an editorial published
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