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Presidential Address

Service: 2010 Western Trauma Association Presidential Address

Mackersie, Robert C. MD, FACS

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The Journal of Trauma: Injury, Infection, and Critical Care: February 2011 - Volume 70 - Issue 2 - p 267-272
doi: 10.1097/TA.0b013e318203157a
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Abstract

Members of the Western Trauma Association (WTA), friends, and guests: I have always been impressed and gratified by the caliber of persons I have had the privilege of working with over the years and their selfless devotion to not just their patients, but to a larger set of ideals, concepts, and activity that extends well beyond the provision of surgical care. The topic of “service” was chosen as an attempt to distill and characterize one of these unifying elements—and something central to our profession and our careers. The topic is also conveniently broad so as to prevent anyone from discerning the precise elements to be discussed and, of course, allows me sufficient leeway to adjust the “mix” right up to the last minute.

It is my hope that, after the next 40 minutes or so, you might gain a slightly different perspective on how we, as members of a profession with a focused interest in a special population of patients, provide, facilitate, and instill in our successors, the ethic of “service.”

The term “service” permeates our culture and our language. It is an almost subconscious rejoinder to the term “military”; it is used in the culinary industry; it has religious connotations, and it is used as the name for a structure by which we deliver patient care (e.g., trauma service). It is incorporated into phrases used in our everyday language and includes terms, such as service industry, public service, professional service, and service line. Those of us who practice medicine belong to a “service industry” (a fact, it seems, that is often forgotten). Considering trauma practitioners help provide a unique and essential public service, those of us in this line of work might even be considered public servants of sorts.

Although there is certainly a place for service to self, the term “self-serving” often implies an associated expense to others. In the context of this discussion, “selfless” service is implied. This discussion is about the activities of service and the products of those activities benefiting others. This discussion is not about us.

The dictionary, in its definition of service, contains at least 15 nouns, 4 adjectives, and 4 transitive verbs (for you grammar buffs). It also contains a colorful reference to one aspect of animal husbandry. For the purposes of this discussion, however, I will use the term service to mean those activities and commitments made and performed that attend to the needs or interests of others. “Others,” in this context may be considered broadly to be inclusive of individuals, groups, organizations, communities, or society in general. The “interests of others” may similarly include those goals or ideals held by individuals, groups, or communities. Service that is performed is ideally voluntary and is presumed to retain the nobility of an activity largely unaffected and uncompromised by monetary compensation. The delivery of service in this context, therefore, is associated with qualities of strong moral character and generosity—it is considered a magnanimous activity.

The Ethical and Social Basis for Service

There are several conceptual underpinnings for the idea of service. These include beneficence, the ethic of reciprocity, and the concept of noblesse oblige. Beneficence, of course, is the search to “do good” in consideration of both individual and the common good. It encompasses acts of charity and acts that involve justice, particularly contributive justice or that which individuals owe to society for the common good. (This is distinct from distributive justice, which refers to what society owes to its individual members.) Service is also conceptually related to the so-called ethic of reciprocity. This ethic encourages us to do for others or their interests that which we would like done for us or for our interests. It is taught to grade school children as “the golden rule” and is an important basis for modern concepts regarding human rights.

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Physicians in general, and surgeons in particular (being among the most privileged group of persons on this planet), presumably have the expectation of providing service as the result of their status and stature within our society. The concept of noblesse oblige, described by Balzac and others in the early 19th century, was originally applied only to the nobility. Although none of us in this room would consider ourselves to be in that category, the underlying concept is still fitting: with privilege and position comes responsibility. Surgeons, through their training, education, and experience, remain highly regarded and well compensated by society. In the narrower realm of trauma care, surgeons are typically regarded (and regard themselves) as being the definitive trauma care providers. With this position comes the responsibility and expectation to contribute their expertise, leadership, and gravitas through service beyond that of direct patient care.

As a preface to the discussion that follows, I would make the following observations:

  • This choice of topic does not by any means suggest or imply that I am somehow a paragon of a service-oriented professional. I make no such pretenses. There are many individuals in this room who arguably have set the standard for making multifaceted and sustained service commitments throughout their professional careers.
  • The goal of these discussions is to recognize, examine, and even celebrate the richness and diversity of service opportunities that are available to all of us. It is also to explore the choices one makes in this regard and to consider how we may better cultivate the ethic of service in our profession and in our trainees.
  • This will neither be a sermon nor a “call to arms.” I will attempt to avoid the use of such terms as “we need to …” or “we must … ” or “you should …” This is not a political speech, I am not running for anything, and language such as this quickly becomes tiresome. What I will try to do is provide a conceptual overview of service, discuss specific service needs now and in the future, and leave you with a few parting thoughts.

It would be presumptuous of me to undertake a discussion of all types of service, and the focus of this discussion will be limited. However, it is appropriate and necessary at this time to recognize and honor the extraordinary contributions individuals make and have made in the service to our country—service to the ideal of freedom and liberty and to the security that protects it. I would ask all those in the room who are serving or who have served in the United States Armed Forces to please stand and be recognized.

[numerous individuals in the room stand to sustained applause]

It would also be remiss of me to fail to recognize two other forms of service to humanitarian crises that is beyond the scope of this discussion:

  • Conflict zones: Service rendered by men and women, who, in the interests of ameliorating the suffering associated with conflicted societies, put themselves in harm's way in an attempt to ease that suffering. Medecins San Frontiers has identified an unfortunately long list of these zones and peoples: Sudan, Darfur, Somalia, Afghanistan, Democratic Republic of the Congo, Sri Lanka, Yemen, and others.
  • International relief and disaster response: Most recently exemplified by the response to the Haitian earthquake of January 2010, the physician and surgeon response through disaster medial assistance team and other government teams as well as nongovernment organizations has been admirable. A more detailed discussion of this response will be the focus of a special session later in this year's WTA meeting.

The concept and value of service is nothing new to this organization. A number of recent WTA past presidents have incorporated the following related topics into their Presidential addresses:

  • Service to education prevention, trauma systems, and political involvement as an inherent part of a trauma career (Cogbill, 1996)1
  • Service to a patient's perspective of serious illness and injury (Jurkovich, 1997)2
  • Service to country, service to groups, programs, and to the community (Thomas, 1999)3
  • Service to the underserved and international medical relief (Shackford, 2001)4
  • The importance and need for service to families of patients (Millikan, 2003)5
  • The “golden rule” (Sugerman, 2004)6
  • Service to the underserved immigrant population (Petersen, 2005)7
  • Service to the disadvantaged in the prevention of domestic injuries (Davis, 2008)8
  • Service to training, mentoring, and being service oriented (Rozycki, 2009)9

The service that most of us provide to the profession may seem a bit mundane, particularly when compared with military or conflict zone service. However, in the aggregate, it is vitally important to our profession, our careers, and to our patients' lives. Most of you in this room have spent a lifetime providing voluntary service beyond basic practice or academic obligations, examples of which are presented here (Table 1).

TABLE 1
TABLE 1:
Examples of Service

What most of us strive to do in our profession and in our careers is to assume responsibility for various elements—conditions, diseases, a base of knowledge, programs or organizations, and even perceptions or perspectives—to work with these elements, to understand them, and to modify them or our knowledge of them in a way that results in overall improvement. We then pass these on to the next person (or generation) to do the same. In this way, we serve with the hope of advancing the profession and ultimately improving the lives of our patients.

The variety of service opportunities that exists is enormous, with many of these involving limited-duration assignments, such as that for the American Board of Surgery, the American College of Surgeons, or professional societies. The infrastructures supporting this service may be variable as well as the continuity of the activity. Redundant service activity sometimes occurs, but, typically (and appropriately), the focus is on the enterprise and results, not on us “volunteers.” In this context, it is perhaps well to remember the old dictum, originally credited to Harry S. Truman: “It's amazing how much you can accomplish if you don't care who gets the credit.”

The Benefits and Obstacles to Serving

Although altruism forms the most important basis for the service that most of us provide, there is an accompanying satisfaction of serving and contributing that provides meaning to these activities and even a legacy of sorts. Collateral benefits to service may include the ability to control and direct an activity or program, intellectual stimulation and knowledge and experience gained, the potential for professional growth and opportunities, peer recognition, the satisfaction of meeting professional obligations (noblesse oblige), and the camaraderie and fellowship involved with a service activity. Even the less altruistic promise of personal prestige or “bragging rights” may be considered among the benefits of serving.

Despite these obvious benefits, it should be acknowledged that the sustained commitment to service would be impossible if it came at substantial personal sacrifice or unsustainable cost. As we examine ways of cultivating and sustaining service-based activities in our profession, the potential obstacles (and burdens) of serving should also be considered.

The obstacles to serving, particularly for future generations, are significant and may be increasing over time. Opportunity costs from loss of practice, loss of time for required academic pursuits, and loss of personal/family time are long-standing factors that have perhaps worsened, as practice performance pressures have increased over the past 5 years to 10 years. Financial burdens from medical education are considerable for many medical school graduates, and the concept that “It is hard to think nobly when one thinks only about making a living” (Rousseau) is as true now as it was over 200 years ago.

With respect to professional organizations and agencies, restricted opportunities within these organizations, and occasionally limited accessibility to some types of service, will sometimes create obstacles to serving. Perhaps a more important impediment is, for lack of a better term, what I will refer to as “service burn-out.” This stems from the inability to say “no”—so pervasive in our profession and instilled in many of us at a relatively young age. The high demand for surgical expertise and leadership skills, coupled with time and travel-intensive activities as well as insufficient offsets, may create situations that are unworkable in the long term for many individuals. There is arguably a cadence and tempo to a career-long provision of service that, if recognized, may be useful in avoiding “service burn-out” situations.

More insidious obstacles to making sustained commitments to service include generational predispositions to focus on lifestyle, family, the perception of a lack of impact or futility of effort involved in some service areas, and perhaps most importantly, the failure to train and cultivate the “ethic of service” in the future generation of professionals. It remains to be seen whether or not we will be producing physicians who are more self-focused surgical technicians and less compleat health care providers engaged in career-long service to the broader goals of their profession and their communities.

There are three areas I would like to focus on briefly for the remainder of this discussion. These include the following:

  • Leveraging service and maximizing its impact through professional organizations
  • The service of leadership related to ensuring access to care and trauma systems development
  • Training in cultivating the ethic of service and sustaining a practice paradigm that facilitates this.
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Figure

Leveraging Service: The Role of Professional Associations

It is believed that Jean Jacques Rousseau's words created, in part, the inspiration for a well-known phrase in John F. Kennedy's 1961 inaugural address. Professional organizations often act as structural surrogates for a profession or specialty practice, and there is a necessary reciprocity in service to and from members of a professional association. Too often, however, members ask “What is this organization doing for me?” rather than the reverse.

It is notable that, in reviewing the mission statements of the trauma-related surgical associations, the mention of “service” is not included. Although it might be argued that the concept of service is implicit within these statements of purpose, this observation supports the notion that the (nonpatient care) service we provide as professionals, both individually and through these organizations, often goes unacknowledged.

In actual practice of course, professional associations can be very effective agents for leveraging individual service—maximizing the impact of individual contributions to a common effort. By their very structure and function, it can be argued that these professional associations have a responsibility to do just this—providing a “community” of volunteers, necessary leadership, and supporting infrastructure. These organizations are at their most effective when service-related participation is product- and outcome-driven rather than being considered purely honorific. Examples of the products of this leveraged individual service are numerous both in and out of the trauma community:

  • Development and facilitation of national agendas and coalitions
  • Defining standards and best practices of the specialty and profession
  • Creating consensus on practice aids: algorithms and guidelines
  • Procuring funding to support initiatives and research through charitable foundations, scholarships, and grants
  • Facilitating training through consensus on program structures
  • Increasing accessibility to extramural service opportunities

With multiple associations working together, utilizing common infrastructures and developing well-aligned overall goals, the effectiveness of individual leveraged service is increased. Balkanization, competition, and “silo'ing” do just the opposite—creating fragmentation and redundancy, with the resulting degradation of this leveraged service.

Some surgical associations have experienced declining membership over the last several years, and a common question asked by potential younger members is “Why should I join, what's in it for me.” The answer is: For the opportunity to leverage individual service. Organizations can leverage service by maximizing the impact of individual service, focusing and coordinating efforts and goals, and providing structure and motivation for trying to get “everyone pulling in the same direction at the same time.”

Trauma Systems and the Service of Leadership

The practice of surgery in general and trauma surgery specifically requires relatively well-developed leadership skills. Trauma is highly self-selecting for practitioners with the skills and psychological profile to make and to lead others in making major decisions, often based on minimal clinical information. This same leadership is a critical element in an organized trauma system.

Trauma systems have been developed based on the strongly held belief that trauma is an essential public health service and everyone, regardless of their geographic location, ethnicity, socioeconomic status, and so on, is entitled to timely access to high-quality trauma care.10 The available data are more convincing than ever, both for survival benefit11 and cost-effectiveness.12 Unfortunately, current evidence suggests that this goal is far from being realized, with the percentage of patients with severe injuries who reach an appropriately designated trauma center still well below an achievable number.13,14 In addition, we continue to be challenged by engrained public perceptions (“it will never happen to me,” “it only happens as a result of irresponsible behavior,” “if it does happen, my local hospital will be able to take good care of me,” and so on).

Within the larger system of emergency medical services and public health, trauma surgeons are often perceived to be at the professional pinnacle of the trauma care delivery system and seemingly expected to possess the classic Roman virtues of gravitas, dignitas, and pietas. These perceptions and expectations create unique opportunities for the service of leadership aimed at helping to establish and ensure universal and timely access to trauma care.

Among the major challenges to achieving this goal are limited physician commitment, incomplete public and legislative education, organizational structures not well suited to implementing change focused on patient outcomes, and the lack of meaningful enticements promoting community hospital participation in a trauma system. The active engagement of surgical practitioners can bring undisputed credibility to public and legislative education; provide knowledge and experience for system-wide, patient-based performance improvement; and help facilitate the development of outreach activities and professional networks critical to trauma system development.

Surgical Training and the Ethic of Service

In his 2001 Western Trauma Association presidential address, Shackford4 noted that there was “the perception that society in general, and medicine in particular, are devaluing the ideals of service and sacrifice.” It is an important observation and needs to be carefully considered in the context of surgical training. As surgeons, we are an integral part of a service industry, but despite this fact, there is little mention made of “service” in the ACGME guidelines for surgical residencies. Although it is stated that “the residency program must require its residents to obtain competencies in six areas to a level expected of a new practitioner” (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and ethics, and system-based practice), there is virtually no direct mention of service as used in the context of this address. The values outlined in Table 2 would be heartily endorsed by most of us, both as practitioners and as surgical educators. They are found within the guiding principles of service industries,15 but many are not specifically promoted as part of “service” expectations within surgical training programs.

TABLE 2
TABLE 2:
Service-Oriented Values

The historical legacy and ethic of service in surgery is largely ignored by current training programs. As such, it is being steadily degraded. There has been increased emphasis on duty-hour restrictions and enforcement; emphasis on education (as opposed to “service”); emphasis on scheduling convenience, skills labs, simulators, and 360° evaluations; and emphasis on checklists and on standardized examinations. There is little or no emphasis made on service and nothing to help establish or cultivate the ethic of service within this noble profession.

The challenge will be in how to inculcate and preserve the ethic of service within a training structure that increasingly ignores it. Although this is important for general surgery residency, it is critical for trauma/acute care surgery fellowships. Trauma surgery is a natural ally of public health and global health, and it is well within our ability to ensure that our fellowship programs provide easily accessible opportunities for exposure to service activity, locally, regionally, and internationally.

Service and the Involving Practice Paradigm

The topic of professional identity was recently addressed by Dr. Jerry Jurkovich in his 2009 presidential address for the American Association for the Surgery of Trauma.16 In that lecture, Dr. Jurkovich identified himself, as many of us identify ourselves, as surgeons and specifically as trauma surgeons. This distinction is noteworthy, for the practice of trauma surgery has an inherent and substantial component of service that exists in few other surgical specialties. Our identity in this regard is important, as is embedding the ethic of service into that identity, and the “brand” that we are or that we will become must have service, in all its forms, inextricably associated with it.

The name “trauma” pertains to a model of disease management; to an ideal of universal access to emergency surgical care; and to prevention, patient care, research, recovery, systems development, and service. It is the name of our centers, our systems, our journal, and our associations. Although this name, ideal, and legacy of service may be extended to a broader scope of surgical practice by whatever name, it should not be subordinated, compromised, or subsumed by it.

As practitioners of trauma surgery, we expect to serve—in the capacity of providing outreach, medical education, care to the underserved, scholarship, prevention, and systems leadership. As our practice patterns evolve and more consistently encompass the management of nontraumatic acute surgical illness, consider the potential we have to expand, (or contract) the ethic of service that has been historically tied to the practice of trauma surgery.

The urgency of guaranteeing access to trauma care (and the future of trauma surgery) has been well recognized and depends on the development of a practice model sufficiently robust to attract and retain future generations of “critical access” surgical practitioners. It depends also on maintaining the legacy and commitment to service, central to trauma surgery, that hopefully will be applied to a broader scope of emergency surgical practice in the future.

Parting Thoughts

Without question, it is a privilege to be a member of this profession—in a place and at a time that provides so many opportunities to serve and against a background of being able to render patient care that has among the most profound of human consequences. Service is one of our core values—mostly implicit and largely underrecognized. Service is an essential element of what we do professionally, personally, intellectually, and spiritually. Service is inextricably linked to our sense of value and purpose.

One of the fundamental missions of our professional associations, particularly trauma organizations, should be to leverage individual service. Doing so permits longitudinal service opportunities throughout a career. It is a responsibility of our professional organizations to effectively utilize financial and human resources to promote and leverage service for and within the organization. The promotion and facilitation of this service on the part of its members is not expected to be a “budget neutral” activity, and leveraging this service may require a financial commitment on the part of an association and its members.

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Figure

With respect to the service of leadership, a commitment to the ideals of prevention and universal access to optimal care is a distinguishing feature, beyond the simple provision of surgical care, of a trauma surgical practice. This surgical leadership in trauma should be regarded as an essential public service. It is an indispensable element in the creation and operation of trauma systems and in ensuring access to care.

The concept and the ethic of service has been progressively deemphasized in our training programs and could lead to progressive de-emphasis in our practice models as well. As we develop and enhance both training models and practice paradigms, consideration must be given as to how to better impart the ethic of service to surgical trainees and the practitioners of the future.

We are at a crossroads in trauma surgery where access to emergency care is increasingly threatened, the ethic of service is slowly being eroded, and the practice paradigm of our successors is uncertain. It is within our capabilities to structure, mold, define, and craft this paradigm in a way that is adaptive to the current healthcare environment, facilitates the ideal of providing universal access to care, and enriches our professional experience. In so doing, the incorporation of the ethic and expectation of service must be coupled with the provision of opportunities to meaningfully serve.

It is an extraordinary honor to belong to this Association; to have had the opportunity to serve as its President, to contribute to its activities, and to have you as colleagues and friends. Thank you for listening, good evening, and God bless.

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REFERENCES

1. Cogbill TH. What is a Career in Trauma? J Trauma. 1996; 41:203–207.
2. Jurkovich GJ. Paint the ceiling: reflections on illness. J Trauma. 1997;43:733–740.
3. Thomas HJ. Grapes to wine. J Trauma. 1999;47:825–828.
4. Shackford SR. “How then shall we live?” J Trauma. 2001;51:1031–1036.
5. Millikan JS. On the other side of the door. J Trauma. 2003;55:1007–1013.
6. Sugerman HJ. WTA Presidential Address: the man in the glass. J Trauma. 2004;57:929–933.
7. Petersen SR. Patients crossing our borders: an ethical or economic conundrum? J Trauma. 2005;59:1037–1041.
8. Davis JW. Domestic violence: The “rule of thumb”: 2008 Western Trauma Association Presidential Address. J Trauma. 2008;65:969–974.
9. Rozycki GS. A gift: Presidential Address at the 2009 Western Trauma Association. J Trauma. 2009;67:1137–1143.
10. “Wherever the dart lands: toward the ideal trauma system” Scudder oration on trauma. October 13, 2009, by A. Brent Eastman, MD, FACS. Available at: https://secure.facs.org/trauma/video/index.html. Accessed October 15, 2010.
11. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–378.
12. MacKenzie EJ, Weir S, Rivara FP, et al. The value of trauma center care. J Trauma. 2010;69:1–10.
13. Nathens AB, Jurkovich GJ, MacKenzie EJ, Rivara FP. A resource-based assessment of trauma care in the United States. J Trauma. 2004;56:173–178.
14. Hsia RY, Wang E, Torres H, Saynina O, Wise PH. Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006. J Trauma. 2010;68:217–224.
15. Service values from the Ritz-Carlton Hotel Company, 2010. Available at: http://corporate.ritzcarlton.com/en/About/GoldStandards.htm. Accessed October 5, 2010.
16. Jurkovich GJ. Identity: 2009 AAST Presidential Address. J Trauma. 2010;68:753–760.
Keywords:

Service; Training; Profession; Education

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