In a recent post Zoom reminiscence, the authors, who started their training and surgical career in a foreign country, discussed the way they felt after completing a long surgical career. We each had immigrated to the United States and experienced the training and work conditions in this country for most of our careers. We each had focused on relatively different aspects of surgery, we had worked in different institutions, and we had experienced life in different ways. Yet, as we looked at our lives in the context of surgery, we shared one feeling, a feeling of joy and privilege. That strong feeling was present despite the challenges that life had thrown our way: we left the land of our birth, we had to adapt to a new culture, and we had faced the challenges that residency training imposed those days: there was no 80-hour week work limit, most residencies required every second night in the hospital for 5 years, 1-week vacation as an intern, 2 weeks as a junior resident. We had to do our own EKGs and Gram stains at night and act as orderlies if a patient needed to have an X ray after 6 pm. The concept of work-life balance was not mainstream. Most residents were not married, and those that were, got divorced at a rate no more than the national average.
Each of us has led a different life within the discipline of surgery, but for 3 international medical graduates, we have been judged as having succeeded and have been well accepted and rewarded by most metrics (Fig. 1). We acknowledge we were challenged, we were often tired, and we did not spend enough time at home or with our children, even after residency when we were married and did have families.
From 3 different perspectives, we came to the same conclusion, it was the balance of the challenges with the rewards. We enjoyed a comfortable life, but that was never the goal. The privilege was to care for another human being, to be emotionally rewarded or thanked even when we failed. Somehow, we never forgot the reason we went to medical school, to participate in helping another human being in some personal way. To embrace the joy and privileges of not only operating and caring but also of encouraging and being encouraged by the bright young minds we helped educate.
We decided to explore in our minds and souls what were the elements that each of us felt contributed to our being able to experience joy while conducting our busy lives in surgery. We thought that sharing practical ways from real lives, elements that helped us remain happy and in balance with our feelings, might be useful to other surgeons, particularly those in the early stages of their career. In the Navaho culture to be in harmony with yourself and your surroundings is “to be in beauty.” We describe those personal and practical aspects from each of our perspectives and review them with a focus on joy rather than on damage, on positivity rather than negativity of our individual experiences.
(CAP) My own journey through the world of academic surgery started in May of 1971 when I joined the residency program in Rosario, Argentina and formally ended in December of 2018 when I stopped seeing patients at the University of Washington. During those 47 years, I experienced successes and failures which, I submit, are no different than those experienced by most surgeons practicing in an academic institution. Like many of my colleagues, I frequently felt challenged, sometimes tired, occasionally frustrated and I certainly had to face and deal with defeat, personally and professionally. Yet, I managed to survive and to thrive and emerged from each challenge with greater strength.
As I look back into those years, with envy toward my young colleagues who are now entering the wonderful field of surgery, my main sentiment is one of joy. It is joy for the privilege that I had to touch the lives of so many people who entrusted their clinical care or their educational needs to me. Since this feeling is probably experienced by most surgeons, what are the elements that made me experience joy? First and foremost is a constant and relentless search for moments that engendered gratitude. I believe that, if one examines the events that one lived during each day of our lives, a practice that I followed routinely (allocating a few precious minutes each evening), one will find something (usually more than one event) that one can be grateful for. In my personal life, those events were frequently, but not always, associated with my practice and/or my relationships with those around me: colleagues and friends. At other times, the events occurred in my private life, a privileged life that I attributed to be, in part, the result of the profession I chose. I realize that some of it was the result of my good luck, occasionally my judgement, and frequently, my choices. I also discovered that at times, the magnitude of the problems we face, as surgeons, mentors, or as a result of fate, may be so overwhelming that the “good moments” of that day or that week, tend to remain in the shadow or become all together invisible. I found that the relentless pursuit of those moments, their intentional search, allowed me to savor them for what they were and that the mere mental representation and my ability to “re-live” the moment engendered the resilience that I needed to overcome the problem of the day. Sometimes, I recognize, one must look hard for the moment of joy in a particular day or week, life can be tricky, but as we turn every rock, and as we look into every cranny of our day, we will find them and they will be comforting, leaving our spirit content, if not surprisingly happy. I do not know if this practice would help others stem away the prospect of burnout, but it is easy enough to try, and it has very little downside.
The second element that I identified has helped me experience joy is engagement. Engagement with professional societies, engagement within my institution, and engagement in a myriad of projects related to education and training of surgeons. I embraced the concept of saying “yes” much more often than saying “no” and have found that this attitude gave me the opportunity to shape a lot of the policies and procedures that, in turn, impacted my practice and my life. That gave me a unique ability to contribute to the organizations I joined, but also gave me the opportunity to meet a diverse group of people with whom I could interact and experience life from many different perspectives. I recognize that engagement takes additional time but have found the rewards often offset the sacrifice.
The third element I identified as helping me find joy has been associated with my expectations. As a rule, I have always set expectations low. I have done what I thought was right, pursued my interests within my own moral compass, and intentionally talked myself out of expecting any kind of rewards associated with my actions. As this practice became more established in my life, I believe that it protected me from disappointments. Furthermore, this practice allowed me to experience joy when expressing empathy, compassion, and a feeling of achievement when doing what I thought was right. In return, I experienced every reward given to me as an unexpected but welcome event that brought joy to my life. I invite others to try this approach, lowering expectations from others while learning how to enjoy what one does, something that one always has full control of, as the endpoint of our actions.
(HTD) “As we express our gratitude, we must never forget that the highest form of appreciation is not to utter words, but to live by them.” These words by President John F. Kennedy have always had a special meaning for me. I have never ceased to wonder and appreciate how it was that I, a boy from a small distant country in the Horne of Africa, 8500 miles away, was given all the opportunity that enabled me to enjoy a successful and enviable academic surgical career in America. Difficult as the workhours were during surgical residency, the excitement of the operating room, and the friendship and comradery of my fellow residents made me appreciate the joy of surgery and limited any tendency to burnout.
As an international medical graduate, I experienced the hardship of having to learn and accept the difficulties of an entirely new culture and put up with prejudice and social disparities. But once immersed in my training, my life and experience changed dramatically. I was in a “bubble” that afforded me security and shielded me from the outside world. I began to realize and acknowledge with gratitude all the support, mentoring, and friendship that I received from my teachers and fellow trainees. They inspired me to work hard and helped me to aspire to a career in academic surgery, a field that made it possible not only to practice clinical surgery but also to train the next generation of surgeons, and to engage in scientific discovery to advance knowledge in the benefit of patients. Each of these 3 components of academic surgery has combined to enrich my life and give me a fulfilling career. I am deeply grateful for the opportunities that I have been given in this country of opportunities. I believe it is the constant realization of this gratitude that has shielded me from burnout.
As surgeons, we frequently reflect on how fortunate we are that patients literally place their faith and lives in our hands when they consent to undergo major operations. This awesome responsibility is always deeply humbling. As surgeons, we are also rewarded with instant gratification as we see our patients recover rapidly from life-threatening illnesses where what we had done has made a difference in saving their lives or restoring them to good health. Few professions can provide the degree of satisfaction that clinical practice can. In those times I felt down and depressed, I always revert to thinking of the great satisfaction my career has given me and this realization predictably dispels the gloom.
One of the greatest gifts in academic surgery is the privilege to educate and train students and residents, who will be the future leaders and practitioners of surgery. All the time, as an academic surgeon, you are both the teacher and the learner. Generations of bright young minds continue to provide you with intellectual stimulation and inspiration. What joy it is to see one of your residents complete his/her training and join you on the faculty as one of your peers or develop a successful surgical practice and become a renowned and valued member of the society.
The research laboratory is particularly a wonderous place where you share intellectual excitement and develop strong bond with your research fellows. As the years pass, you realize that your fellows are part of your extended family, wherever in the world they may settle after completion of their training. I regard them as the greatest rewards of my academic career.
My career in academic surgery opened another career pathway in administration that I never planned: as Department Chair, Dean of Medicine, and Chancellor of a University. Before I assumed these positions, I had held a cynical view about the role of administrators. I quickly learned, however, that administrators can make a huge difference in the allocation of resources and in opening doors of opportunity. I came to realize that for surgeons to shy away from taking administrative positions was a lost opportunity. I also came to believe that surgeons have a unique capacity of implementing ideas and plans with decisiveness that gives them advantage as administrative leaders.
I believe that I have not merely “uttered words of gratitude” and appreciation but, as my career shows, I have also “lived by them,” to quote President Kennedy.
(MFB) I have previously written of my belief that my life was an extension of winning the birthing lottery.1 Like my colleagues I was an international medical graduate. I was then given another gift, the chance to be here, be educated in an outstanding residency, and continue what I think of as a charmed life. Residency was tough, every second night sleeping in the hospital for 5 years, four if you were lucky or received recognition for research or time spent elsewhere. Tired and exhausted I may have been, but disheartened, no residency was selfish, I was not married and certainly too exhausted to develop any meaningful personal relationships, outside the hospital. I had no competing life. But with the rose-tinted glasses of retrospection, I enjoyed it, loved would be too strong a word. But the collegiality, the camaraderie, the friendships made that have lasted 50 years, another gift. Postresidency, beginning 10 years after finishing medical school, things changed; a spouse, children, a desire to create my own identity all challenging and competing. An initially working physician wife helped, and yet was able to remain a remarkable mother. Having established myself as a clinician investigator I moved to a position where I would spend the rest of my professional life, maybe the rest of my life. That was challenging, a young man in an entrenched Institution, not known for welcoming outsiders. Looking after cancer patients is not a part-time job, and if you try to embrace, as I believe you should, care for a patient from diagnosis to demise, accepting that others would certainly help when surgery alone was not enough, was hard. There was a price to be paid, that price mostly devolved to my spouse and my children. I loved what I was doing. I was selfish, I made choices; I accepted the demands, and my family did pay a price.
So why was I not burnt out? Was I and refused to acknowledge it? Was my personal selfishness in being absorbed in what I was doing, just a different definition? Was my self-absorption, just a different sign? Certainly, there were times when I knew I had to regroup, usually threatened by a nightmare where my children became my patients. Should I have recognized a comment “Dad we are not one of your fellows,” surely that was a sign of ““burnout,” why do I think it was not?
The hours, the tiredness, the sadness of a failed operation, the postoperative complications were all taken in stride. How to explain that? In retrospect, there were several factors. The balance was the emotional rewards, the privilege to help care for courageous patients, the acknowledgment of privilege to enjoy the trust and confidence, deserved or not, from patients and families. How is it that the family of the patient whom you were unable to resect gives you a gold pen? But there were other reasons, I was surrounded by bright young talented residents and especially fellows, who were intellectual and technical sponges, they believed in what we were doing. To watch them grow every day as if it was springtime and the rain was coming for the first time, what a gift. Then there was the resilience, the unaware but real absorption of the failures as tools to grow.
In mid-career, I suffered a serious hand injury. I imagined my operating days were over. Three months later, my reflex dystrophy resolved by the amputation of a nonfunctional digit attachment, I was able to return to the operating room wiser and ever more grateful for being a surgeon.
As my career progressed, I became more resilient. I was blessed with one additional factor: I had (mostly) control of my time. I was able to over-book and over schedule, but that was my choice. I could accept appointments to national committees and write papers, but they were choices. Yes, I did not pass the “I feel guilty when I say, NO” test.
How can I put a measure of value on the excitement of new discovery, the pleasure of maturing operative performance, the discovery of new knowledge, new techniques, new therapies, the translation from bench to bedside? These elements along with the sheer joy of seeing a young colleague or trainee succeed and the privilege of being surrounded by like-minded people brought significant joy to my life. Create not imitate, lead not follow are fulfilling mantras.
I did pay a price for my behaviors, but I made those choices. Could I have made different and better personal choices? Perhaps, but would I? if given another chance, probably not.
During the last few years, I have observed one change that I believe would have been capable of causing me to acknowledge and become burnt out: The ever-increasing demands of compliance, mandatory learning, and electronic medical record documentation. How appalling that seems now as I look at the multiple mandatory learning requirements. How much better to spend that time at the bedside or in the laboratory. I do not believe you can mandate good empathetic care; you must practice it. So, my advice to my younger colleagues is to fight back if you can, take an interest in how your institution is run. Challenge the regulators, interpret the intent of the law not over implementation of the letter of the law. A good start would be to abolish any single mandatory learning program longer than 15 minutes. It is easy to describe and wallow in what makes us unhappy. It is hard to know what makes us fulfilled and happy, but there are choices, try to fill your life with more happiness than frustration. Join with colleagues to make the system work for you not against you. Easy for me to say, hard for you to do. What a privilege it is and was to care for another human being. Is that not why we went to medical school?
In this article, we identify and describe elements that, in each of our lives, have helped us experience the joy of our profession. In so doing, we intended to examine aspects that we believe are common to, or can easily be incorporated into, the lives of practitioners of surgery. We hope that they will not only enhance surgeon's resilience to burnout but rather, substantially improve the chances of personal happiness and satisfaction with the profession. We do not intend to promote our findings as the only solution to the real problem of burnout – but we thought it worthwhile to examine the lives of surgeons from a more positive perspective. We acknowledge we made choices, we made personal, professional, and family decisions that would not be the choices of many. But they were our choices, and we lived with them.
We did so as we believe that “positivity” is one of the major factors affecting the ability of humans to express resilience. Resilience, which in its simplest form is our ability to “bend” but not break, is a major deterrent to burnout. Human emotions, the feelings that are elicited by our daily interactions with our surroundings can be categorized into “positive,” “negative” and “neutral.” Certainly, the environment in which we live, and our profession as surgeons, present us constantly with challenges that could elicit negative feelings (negativity). Finding ways to identify, savor, and nurture the circumstances that drive positive feelings is key not only to remain in balance but also to thrive. Indeed, Fredrickson and others have described a ratio (positivity/negativity), and identified a pivotal point of 3:1.2,3 Those with a ratio of 3:1 or greater seem to enter what the authors call an upward spiral that broadens their mind, expands the ability to connect with self and others and is capable of influencing positively those around them. People with a 3:1 ratio or greater develop a sense of “oneness” that increases their desire to help others in need, and in turn, those actions result in greater joy for themselves and those that surround them. Individuals who express this high ratio have a unique ability to be able to reframe bad events as opportunities, they have a greater ability to express love, experience joy, gratitude, calmness. Negativity is also important. Without it, one loses touch with reality. The relationship of positivity to negativity has been compared to that of the area of the keel to that of the sail of a boat. Both are necessary to navigate, yet the sail must be at least 3 times larger than the keel. Our experiences suggest that we can draw from our profession as surgeons, and that, as we learn how to identify and savor positive emotions associated with our work and life, and as we look intentionally into all experiences lived during a day or a week, we can train ourselves to develop the “muscle” of resilience. One of the most powerful elements in the development of resilience is the ability to establish meaningful connections with those who surround us. That is why we remind young trainees and faculty that their ability to make lifelong friends among their peers is a gift that they will enjoy for life.
We are very sensitive to the current and appropriate increased awareness of social disparities. They were present at the time of our arrival in the United States and we were aware that our “foreignness” was a barrier to acceptance into a residency, but once accepted we did not feel anything but tolerance and camaraderie.
In contradistinction to the hierarchy imposed by tradition, privilege, and patronage in many other countries, we felt most fortunate to be able to access a relative meritocracy. We recognize that our experience with regards to training in the US and the feelings it generated, may not have been shared by others who were/are less fortunate. We may have been foreign, but once accepted, barriers based on language or color seemed less evident than they are now, such that we always looked back at our training with joy and gratitude. Because we recognize that prejudice and social injustice continue to afflict our society, we have individually and collectively tried hard to ensure access without bias for trainees and faculty to the programs that we were fortunate to lead and we have provided opportunities for advancement in a culture of inclusion. We fostered inter-dependence without loss of individuality among our residents and faculty. We encourage all those who lead training programs and who also have a role in determining the future of their graduates, to embrace a culture of diversity and inclusion. They will be, as we were, rewarded with the richness of ideas that can only emerge from such a culture.
Successful cultures are characterized by individuals who can express gratitude, a sense of perspective, and responsibility for most-of what-happens to them.4 The ability to identify, recognize and savor the many gratifying moments of our profession we believe is a powerful tool to the development of resilience, the resilience that is necessary to face the problems that life and our profession bring, and that may also provide an antidote to burnout.
We acknowledge that our professional lives ended up being different than that of most practicing surgeons. We were in academic institutions, we eventually became chairs of large departments, and that placed us in a privileged position with access to resources and personnel not readily available to all surgeons. We were able to choose, a large clinical practice, an active investigator program, a role in leadership, and always an active interest in education. Always “what did you learn today? What did I learn today?”
We were males at a time when surgery was a male-dominated specialty, and we realize that female surgeons, face greater challenges than males. And yet, we faced challenges of our own, some because we were immigrants, some because we became Chairs and had to deal with the unique challenges posed by our position. And although our lives or experiences may not be generalizable, we believe that the principles expressed here may be useful to some. Our purpose was to emphasize the joy of our profession amidst a growing body of literature that focuses on the negative aspects of surgery.
In today's world we all strive to find purpose and meaning to our lives. We believe our profession is uniquely positioned to provide just that. The patient needs us from diagnosis to the completion of successful or not so successful treatment and we are certainly rewarded by and for our work. Yet, this theoretical framework, which on the surface seems to be perfect to provide meaning and purpose to the life of a surgeon, is only useful in as much as the person is willing to intentionally devote some time to discover her or his place within it. That is why perspective is so important, and why meditation is key to the identification and savoring of those moments that bring us to the state of joy. That is why engagement with projects, professional and community organizations, can enrich our lives.
We continue to face challenges from our patients, our former students, our colleagues, and our projects, but that too is a privilege. We encourage our colleagues to develop a discipline that constantly searches for moments that bring satisfaction, that bring hope, that close the gap between us and those that surround us. We hope that others can come to where we have come, grateful for the privilege of being a surgeon.