the joy of the master

One of the must-have textbooks for a young surgical resident is Mastery of Surgery. It’s a two volume tome detailing the rationale and methods of surgical technique for pretty much every operation we do. Everything from the old Halsteadian radical mastectomy to the laparoscopic Heller myotomy is in that baby. It’s a wonderful book. I still peruse through it the night before big cases. But I always hated the title when I was a younger resident. Mastery of surgery. It sounded so typically pompous and bombastic; what one would expect from staid, formalistic surgical academia. The word “mastery” nagged at me, hinted at something overwrought and unattainable. How could one ever think it would be possible to master all the vagaries and intricacies of general surgery?

But my understanding of what it meant to master a profession was woefully inadequate. It isn’t about memorizing the steps to a bunch of operations. What I didn’t understand was that it was the vagaries and intricacies themselves that separate a true master from the journeyman. You give an apprentice a nice piece of wood and first class tools and the proper instructions, there’s a good chance he’ll be able to pound out a decent bookcase for you. It will be sturdy and durable and it won’t draw negative attention to itself. But a master carpenter can take a bundle of scrap wood and some shabby blunted tools and he’ll create a work of art, a centerpiece that guests ask about when they enter your home. Excellence under adverse conditions. A master surgeon is similar in this regard.
I had the privilege of working with such a master surgeon in Chicago as a resident at Rush University Medical Center. Dr. Alexander Doolas was in the latter stages of his career when I was there but he was still one of the busiest surgeons in the hospital. Dr. Doolas is cut from that old school cloth of pure bad ass, no holds barred, no nonsense, work all night, take no excuses, knows more than everyone and isn’t afraid to tell you kind of surgeon that used to rule the roosts at big academic centers. (Surgery has now evolved into its kinder and gentler phase of development with work hour reform and the civilizing influence of more women entering the field.) Dr Doolas is about 5’6″ and his physique is cut like one of those Bulgarian power lifters. He’s always tanned and well dressed outside the OR with his hair immaculately slicked back like Al Pacino in Scent of a Woman. Merely standing in his presence as an intern was terrifying enough. But then he’d open his mouth and this alpha-male, heavily-Greek accented deep baritone would come growling out and you’d literally start dropping pens and papers and maybe even slightly losing control of your sphincter mechanism if you’d done something wrong or forgot a crucial detail. He scared the hell out of me that first year. He was notorious for calling interns randomly in the middle of the night for updates on his ICU patients. The page would come in from an outside line and you’d sprint down to the unit to review the bedside flowsheet before calling it back. And you couldn’t make numbers up because Dr. Doolas would often first call the ICU nurse to get the actual answers and compare it with what you told him. So we all ended up hanging out down in the ICU most call nights until after midnight, just in case the old man wanted an update. His big thing was fluids and electrolytes. The man lived for sodium concentrations and potassium losses in bile and the exact chloride composition of pancreatic secretions and urine outputs and the precise balancing of fluid intake versus fluid losses. After Whipples he put in G-tubes (gastrostomy tube) and decompressive J-tubes (jejunostomy) and feeding J-tubes and an NG and you needed to know how much was coming out of each and what it looked and even what it smelled like. He thought he could smell when there was a pancreatic leak. You’d see him digging around on a post-op belly with his bare hands sniffing the end of the drains to determine his next move. Patients with delayed gastric emptying after a Whipple can often lose a lot of water and sodium via NG and G-tube decompression. He sometimes liked to replace those losses not with saline infusions but with the actual fluid itself. So nurses would have to collect the G-tube and decompressive J-tube outputs, put it in a plastic bowl on ice and then refeed it via the feeding J-tube every shift. It was gross but it made sense. It was perfect actually.
On rounds, it was the Dr. Doolas show. He had this charismatic, disarming, eccentrically charming bedside manner that patients just ate up. They loved him. He projected pure confidence and rightness of action. He could walk into an old man’s room who’d had a left colectomy and Dr Doolas would pontificate for twenty minutes on how the Persians invaded Greece unprovoked and how they got their comeuppance, and then maybe at the end, right before abruptly leaving, tell the patient that he needed to start eating more potatoes and the patient would nod enthusuastically, as if the Holy Ghost Himself had paid him a visit. He also liked to speak in metaphors. I remember this high maintenance suburban patient who had had a pancreatic resection and she had a thousand questions for Dr Doolas about what was happening and why he was doing certain things. You could tell he was getting annoyed. He took off his glasses (always a sign of something legendary about to happen), started gnawing on the tip, and he held up his hand and that deep voice rolled out at her like a surging wave, “Listen! When you get on an airplane and you’re flying to Milwaukee to see your cousin Angelo, do you get up out of your seat and go knocking on the pilot’s door and ask him what that knob is and why that light is flashing and how’s come the dashboard is beeping like that? Do you? No. You don’t. So you let me fly this plane.” Some of his metaphors, however, tended to be seemingly ad libbed and barely coherent. You could ask him why he wanted to restrict a patient to scrambled eggs without the yolks, red beans, and unbuttered toast and you were liable to get an answer along the lines of: “Listen. When you get on the bus and you want to get to Evanston there’s always an old lady sitting next to you asking if you know where her recipe book is and meanwhile there might be an elephant at the next stoplight but you don’t know you so you have to count backwards from 57 by threes until you get to the second prime number and then it’s like when the Inuits crossed the Bering Strait and it all becomes obvious. You got it?” And he’d stare at you like you were the stupidest person on earth, your mouth agape, wide eyed, not knowing what in the hell to say, and he’d finally just shake his head and walk away.
In the OR Dr. Doolas was legendary. He was famous for the two hour Whipple. The 20 minute colectomy. He’d hunch over the table, his giant bald head inches from the pancreas, headlamp illuminating an orb of intimate anatomy, and everything he did, every move was filled with purpose. He didn’t move fast, he just didn’t waste any action. Every maneuver served the purpose of advancing the operation toward its logical conclusion. There was no dicking around, no hemming and hawing, no tentative picking and pawing at tissues. He knew where he was at all times, where he needed to go, and what was necessary to facillitate that end. He didn’t let the residents do much unless you were a chief and then, only if he liked you. But operating with Dr. Doolas was beside the point. It was enough to just watch the man in action. Two cases come to mind.
The first was a lady who had been referred to Dr Doolas from an outside hospital. The poor lady had been suffering from an enterocutaneous fistula for over a year. She’d had multiple operations and she hadn’t been eating and she just seemed broken and defeated. Green bile leaked from her fistula near the belly button. Scars criss-crossed her abdomen. She looked gaunt and emaciated. Everyone else had given up on her. Dr. Doolas reviewed her scans and xrays and put her on the OR schedule for the next day. Under anesthesia he made a single incision through the midline scar and it soon became apparent we were dealing with a frozen abdomen. A patient who has had peritonitis and multiple operations can develop so much scar tissue that all tissue planes are obliterated; it’s as if someone has poured cement between the loops of bowel. There’s no free space. Everything is socked in, frozen in place. Every move you make is fraught with hazard. It’s easy in these situations to do more harm than good. It’s a situation that most surgeons try to avoid and that’s why a lot of them end up ultimately with surgeons like Dr Doolas. After the initial incision, Dr. Doolas asked for a hemostat. For the next 60 minutes that’s all he used. I watched him wield that blunt tip of the hemostat like chisel, chipping and scraping and carving his way through the scar and granulation tissue until he had isolated the loop of bowel involved in the fistula and separated it from the abdominal wall. It was like watching Rodin create a masterpiece out of a block of granite. In ninety minutes he completed what would have taken any other surgeon 6-8 hours. The patient went home in 4 days, happier than she had been in over a year.
The other case was a thin guy who had had an esophagectomy with a gastric pull-up a number of years ago at an outside institution. He then developed a stricture at the esophagogastrostomy anastomosis in the neck. A previous revision had re-strictured. Multiple attempts at balloon dilatation had failed. Now the man could not swallow even a glass of water. He was dependent on a feeding jejunostomy tube for nutrition. But he missed eating. He missed being able to cut up a perfectly cooked filet, chewing, savoring the juices, the act of swallowing. He wanted to experience it again. No matter what. Telling him no would have been entirely reasonable. He was living at home, surviving, getting by. There was no emergent rationale for further intervention other than the patient’s consuming desire to eat again. Dr. Doolas was his last hope. No one else would take the case.
The day of the operation, Dr. Doolas was in one of his happy moods, razzing everyone, laughing easily, seemingly unperturbed by daunting task at hand. Any redo surgery is tricky and trying to revise an anastomosis in the neck for the second time is especially perilous. The neck is a small, contained space and important nearby structures like the recurrent laryngeal nerve and the carotid sheath are at risk of injury. It’s a veritable hornet’s nest of danger. But once again I watched Dr. Doolas use just a scalpel and a dissecting clamp to carve through dense scar tissue until, miraculously, the striated meaty fibers of the proximal esophagus appeared. From there, he worked his way down to the old anastomosis. Once eveything was dissected out he looked over at me, eyes glinting, and he tossed his head back and laughed, a deep hearty laugh, a guttural guffaw, a sonorous, soulful, Count Dracula sort of laugh from the depths of his being. His hands were momentarily at rest. The moment lingered. And then he started again. Ten minutes later he’d resected the stricture and created a widely patent new end to end anastomosis. The entire case took about 45 minutes. The patient was eating a hamburger three days later.
A master at work. All I did was run the sucker and tie some knots but I learned more from those two cases than in any operation where an attending allowed me to stumble my way through the maneuvers. Just watching. Seeing things the way Dr. Doolas saw them. The sense of undauntedness that he brought to a case. The confidence. The experience and knowledge. The creativity and vision. But I think there was something else, something you can’t teach, maybe the most important thing. And it was all contained in that simple baritone laugh, his head tilted back, eyes slightly closed. It was the laugh of pure joy. For in that one brief moment the true master of surgery realizes a rare perfection, the uniqueness of his talents that have allowed him alone to actualize the healing of a complicated patient. There may not be a happier feeling in the world for those chosen few. Without that innate sense of joy, real unadulterated child-like joy, true mastery is unattainable no matter how many books you read or where you train or how many Whipples you watch…..

THE USES OF DIFFICULTY

The brain likes a challenge—and putting a few obstacles in its way may well boost its creativity. Ian Leslie takes a hard line...
From INTELLIGENT LIFE magazine, November/December 2012
Jack White, the former frontman of the White Stripes and an influential figure among fellow musicians, likes to make things difficult for himself. He uses cheap guitars that won’t stay in shape or in tune. When performing, he positions his instruments in a way that is deliberately inconvenient, so that switching from guitar to organ mid-song involves a mad dash across the stage. Why? Because he’s on the run from what he describes as a disease that preys on every artist: "ease of use". When making music gets too easy, says White, it becomes harder to make it sing.
It’s an odd thought. Why would anyone make their work more difficult than it already is? Yet we know that difficulty can pay unexpected dividends. In 1966, soon after the Beatles had finished work on "Rubber Soul", Paul McCartney looked into the possibility of going to America to record their next album. The equipment in American studios was more advanced than anything in Britain, which had led the Beatles’ great rivals, the Rolling Stones, to make their latest album, "Aftermath", in Los Angeles. McCartney found that EMI’s contractual clauses made it prohibitively expensive to follow suit, and the Beatles had to make do with the primitive technology of Abbey Road.
Lucky for us. Over the next two years they made their most groundbreaking work, turning the recording studio into a magical instrument of its own. Precisely because they were working with old-fashioned machines, George Martin and his team of engineers were forced to apply every ounce of their ingenuity to solve the problems posed to them by Lennon and McCartney. Songs like "Tomorrow Never Knows", "Strawberry Fields Forever", and "A Day in the Life" featured revolutionary aural effects that dazzled and mystified Martin’s American counterparts.
Sometimes it’s only when a difficulty is removed that we realise what it was doing for us. For more than two decades, starting in the 1960s, the poet Ted Hughes sat on the judging panel of an annual poetry competition for British schoolchildren. During the 1980s he noticed an increasing number of long poems among the submissions, with some running to 70 or 80 pages. These poems were verbally inventive and fluent, but also "strangely boring". After making inquiries Hughes discovered that they were being composed on computers, then just finding their way into British homes.
You might have thought any tool which enables a writer to get words on to the page would be an advantage. But there may be a cost to such facility. In an interview with the Paris Review Hughes speculated that when a person puts pen to paper, "you meet the terrible resistance of what happened your first year at it, when you couldn’t write at all". As the brain attempts to force the unsteady hand to do its bidding, the tension between the two results in a more compressed, psychologically denser expression. Remove that resistance and you are more likely to produce a 70-page ramble. There is even some support for Hughes’s hypothesis from modern neuroscience: a study carried out by Professor Virginia Berninger at the University of Washington found that handwriting activated more of the brain than keyboard writing, including areas responsible for thinking and memory.
Our brains respond better to difficulty than we imagine. In schools, teachers and pupils alike often assume that if a concept has been easy to learn, then the lesson has been successful. But numerous studies have now found that when classroom material is made harder to absorb, pupils retain more of it over the long term, and understand it on a deeper level. Robert Bjork, of the University of California, coined the phrase “desirable difficulties” to describe the counter-intuitive notion that learning should be made harder by, for instance, spacing sessions further apart so that students have to make more effort to recall what they learnt last time. Psychologists at Princeton found that students remembered reading material better when it was printed in an ugly font.
Scientists from the University of Amsterdam recently carried out a series of experiments to investigate how obstacles affect our thought processes. In one experiment, people were set anagram puzzles to solve, while, as an obstacle to concentration, a series of random numbers were read out. Compared with those in a control group who performed the same task without this distraction, these subjects displayed greater cognitive agility: they were more likely to take leaps of association and make unusual connections. The researchers also found that when people are forced to cope with unexpected obstacles they react by increasing their "perceptual scope"—taking a mental step back to see the bigger picture. When you find your journey to work blocked by a construction site, you have to map the city in your mind.
As a poet, Ted Hughes had an acute sensitivity to the way in which constraints on self-expression, like the disciplines of metre and rhyme, spur creative thought. What applies to poets and musicians also applies to our daily lives. We tend to equate happiness with freedom, but, as the psychotherapist and writer Adam Phillips has observed, without obstacles to our desires it’s harder to know what we want, or where we’re heading. He tells the story of a patient, a first-time mother who complained that her young son was always clinging to her, wrapping himself around her legs wherever she went. She never had a moment to herself, she said, because her son was "always in the way". When Phillips asked her where she would go if he wasn’t in the way, she replied cheerfully, "Oh, I wouldn’t know where I was!"
Take another common obstacle: lack of money. People often assume that more money will make them happier. But economists who study the relationship between money and happiness have consistently found that, above a certain income, the two do not reliably correlate. Despite the ease with which the rich can acquire almost anything they desire, they are just as likely to be unhappy as the middle classes. In this regard at least, F. Scott Fitzgerald was wrong.
Indeed, ease of acquisition is the problem. The novelist Edward St Aubyn has a narrator remark of the very rich that, "without the editorial influence of the word ‘afford’, their desires rambled on like unstoppable bores, relentless and whimsical at the same time." When Boston College, a private research university, wanted a better feel for its potential donors, it asked the psychologist Robert Kenny to investigate the mindset of the super-rich. He surveyed 165 households, most of which had a net worth of $25m or more. He found that many of his subjects were befuddled by the infinite options their money presented them with. They found it hard to know what to want, creating a kind of existential bafflement. One of them put it like this: "You know, Bob, you can just buy so much stuff, and when you get to the point where you can just buy so much stuff, now what are you going to do?"
The internet makes information billionaires out of all of us, and the architects of our online experiences are catching on to the need to make things creatively difficult. Twitter’s prodigious success is rooted in the simple but profound insight that in a medium with infinite space for self-expression, the most interesting thing we can do is restrict ourselves to 140 characters. The music service This Is My Jam helps people navigate the tens of millions of tracks now available instantly via Spotify and iTunes. Users pick their favourite song of the week to share with others. They only get to choose one. The service was only launched this year, but by the end of September 650,000 jams had been chosen. Its co-founder Matt Ogle explains its raison d’être like this: "In an age of endless choice, we were missing a way to say: ‘This. This is the one you should listen to’."
Today’s world offers more opportunity than ever to follow the advice of the Walker Brothers and make it easy on ourselves. Compared with a hundred years ago, our lives are less tightly bound by social mores and physical constraints. Technology has cut out much of life’s drudgery, and we have more freedoms than ever: we can wear what we like, sleep with whom we want (if they’ll sleep with us), and communicate with hundreds of friends at once at the click of a mouse. Obstacles are everywhere disappearing. Few of us wish to turn the clock back, but perhaps we need to remind ourselves how useful the right obstacles can be. Sometimes, the best route to fulfilment is the path of more resistance.

Momentum

Donald Trump paraphrased on that little thing called ‘Momentum’:

1. To be a big success in any field, you need to build momentum. Momentum is all about energy and timing.

2. When you start anything new, you don’t have momentum. That is when things are hard. People are not calling you. You don’t seem to be getting anyway. If you keep working towards your goals, one day at a time, pretty soon you will get into the flow of people and events. You get contacts, you gain credibility. You build a track record of success. Then things get much easier. Why? Because you have momentum.

3. Do not take momentum for granted. If you lose your momentum, things are much more difficult to get back into. It is harder to do anything when you have lost your momentum. Your finger is off the pulse and your timing is off. People and events are no longer in your favor. So watch out to never lose your momentum - the most likely time this will happen is when you taste a little success and think you don’t need to work hard anymore.

- Sir Darren

Much more than perfect, plus quam perfect. DREAMS REALLY DO COME TRUE

If you'd gone your way 
And I'd gone mine 
We wouldn't be standing 
Where we are tonight 

The room is silent 
All eyes on me and you 
I guess it happens 
Dreams really do come true 

Be my shelter 
Be the one 
Be the witness to all that I become 
We'll have our moments 
There'll be hard times 
But I'll forgive your sins if you forgive me mine 

All the good in my life 
Everything that is right 
Now I know where life is taking us 
This love has brought us so far 
Don't ever change who you are 
Never think that you're not good enough 
You're more than perfect for the both of us 

Let's write the pages 
Build a home 
From this day forward 
You will never be alone 

When we're dancing 
Barefoot in the hall 
If you should stumble 
I will not let you fall 

All the good in my life 
Everything that is right 
Now I know where life is taking us 
This love has brought us so far 
Don't ever change who you are 
Never think that you're not good enough 
You're more than perfect for the both of us 

This world is forgiving 
And I give myself to you 

All the good in my life 
Everything that is right 
Now I know where life is taking us 
This love has brought us so far 
Don't ever change who you are 
Never think that you're not good enough 

No one of us ever will be close enough 
You're more than perfect for the both of us

The Color (Sibghah) of Allah (SWT)

The Color (Sibghah) of Allah (SWT)

"Our Sibghah is the Sibghah of Allah and which Sibghah can be better than Allah's? And we are His worshippers" (Surah Baqarah v. 138)

Have you seen shopkeepers in Pakistan dieing ladies scarves in various colors? The scarf containing original colors comes out with the color of the die. So what is the sibghah (color) of Allah? It is tawheed (Islamic monotheism)! The similitude of a non-Muslim entering Islam is like dieing his multicolored mind and heart with principles of tawheed.

Islamic theology is an integrated whole in which different parts interact with each other. One principle reinforces the other to give an holistic perspective of life. This reinforced version of Islamic philosophy provides a Mumin with the wisdom to understand different things from one perspective (Reality). When someone submits to Allah, one is bound to enter the deen completely. All fabric of his thought must be dyed with the Sibghah of Allah. No thread can be left untouched. He is not supposed to keep a multi-patched outlook to life. Islam should penetrate all aspects of his life; be it personal, family, community, national, international, economic, educational, etc. Influences from other philosophies which contradict reality has no place in his perspective.

For many of us, our commitment to Islam is motivated by social conformity, rather than conformity to its principles. A lot of us have spent a lifetime in studying some branch of knowledge for our professional development. How much time have we invested in studying & implementing the Sibghah of Allah in our lives? Is it not then surprising then to find individuals who emphasize one aspect of the religion which ignoring other aspects?

Unfortunately, these days the principles of materialism affect most of us. We compete with each other in wealth & status and use religion as a tool in this race. Let us change our situation and re-enter the die of Allah (SWT) by being His true worshipers in all aspects of His religion.

http://oak-gis.blogspot.com

AMOR FATI

Amor fati is a Latin phrase loosely translating to "love of fate" or "love of one's fate". It is used to describe an attitude in which one sees everything that happens in one's life, including suffering and loss, as good. Moreover, it is characterized by an acceptance of the events or situations that occur in one's life.
The phrase has been linked to the writings of Marcus Aurelius, who did not himself use the words (he wrote in Greek, not Latin).[1]
The phrase is used repeatedly in Friedrich Nietzsche's writings and is representative of the general outlook on life he articulates in section 276 of The Gay Science, which reads:
I want to learn more and more to see as beautiful what is necessary in things; then I shall be one of those who make things beautiful. Amor fati: let that be my love henceforth! I do not want to wage war against what is ugly. I do not want to accuse; I do not even want to accuse those who accuse. Looking away shall be my only negation. And all in all and on the whole: some day I wish to be only a Yes-sayer.
Quotation from "Why I Am So Clever" in Ecce Homo, section 10:[2]
My formula for greatness in a human being is amor fati: that one wants nothing to be different, not forward, not backward, not in all eternity. Not merely bear what is necessary, still less conceal it—all idealism is mendaciousness in the face of what is necessary—but love it.

Protocols alone cannot keep patients safe, we need a culture (of safety)

Emergency General Surgery (R2) - VUMC

EGS Service OverviewThe Emergency General Surgery (EGS) service is comprised of faculty in the Department of Surgery, residents at the PGY-5, PGY-2, and PGY-1 levels, as well as dedicated Nurse Practitioners. The EGS service evaluates nearly 1,200 patients each year, and serves as the primary consult service for acute general surgical diseases from within Vanderbilt University Medical Center as well as surrounding communities. The primary mission of the EGS service is to provide timely surgical assessment and operative management of the patient with an acute general surgical problem.

Core competencies as defined by the ACGME form the basis of resident evaluations.

1) Patient Care

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

For PGY-2 residents on the EGS service, this will largely take place in the context of perioperative care with the support and guidance of chief residents and faculty. The PGY-2 resident functions as the main consult resident for the service. The PGY-2 should also continue learning to interpret imaging studies such as plain radiographs, ultrasound, and CT scan of the abdomen. Morning report provides a forum to discuss new patients and review imaging studies with faculty and other residents. Operative skills are further developed during the PGY-2 year with increasing participation in a variety of operations as detailed below.

2) Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

The Surgical Council on Resident Education (SCORE) has defined an excellent curriculum for the traditional 5 year General Surgery training program. This has been further grouped to aid in sequencing the material by PGY year. For the PGY-2 year grouping, diseases and conditions which may be encountered on the EGS rotation include:

• Choledocholithiasis • Biliary Pancreatitis • Acalculous Cholecystitis and Biliary Dyskinesia • Iatrogenic Bile Duct Injury • Small Bowel Obstruction and Ileus • Acute Mesenteric Ischemia: Arterial, Venous, and Nonocclusive • Lower Gastrointestinal Bleeding • Diverticular Bleeding • Diverticular Fistulae • Colonic Polyps • Colonic Cancer • Gallstone Ileus • Gallbladder Polyps • Mesenteric Cyst • Miscellaneous Hernias • Hepatic Abscess • Mallory-Weiss Syndrome • Peptic Ulcer Disease with Bleeding • Peptic Ulcer Disease with Perforation • Peptic Ulcer Disease with Obstruction

• Gastric Ulcer • Stress Gastritis • Volvulus • Appendiceal Neoplasms • Antibiotic-Induced Colitis • Meckel's Diverticulum • Intussusception • Malrotation • Pneumatosis • Addisonian Crisis • Incidental Ovarian Mass-Cyst • Cervical Lymphadenopathy • Necrotizing Fasciitis • Gastrointestinal Failure • Hepatic Failure • Renal Failure • Coagulopathy • Neurologic Dysfunction • Endocrine Dysfunction

One of the most effective ways to retain knowledge while at the same time improving the care of your surgical patients is to read about the diseases and conditions faced by patients as you encounter them.

3) Practice-based Learning and Improvement

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.

A good technique to achieve this objective is to review evidence-based guidelines (e.g. Cochrane Reviews: http://www2.cochrane.org/reviews/ ), as well as critical reading of relevant articles in the surgical literature. Self-evaluation as it relates to patient care is best performed in real-time by seeking feedback and discussion from senior residents and faculty. (i.e. What could I have done differently?)

4) Interpersonal and Communication Skills

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Residents are expected to conduct themselves in a courteous and professional manner when interacting with patients, families and nursing staff. Good communication is critical to patient care, particularly in the emergency setting. Examples of specific elements which are of value throughout surgical training and practice include:

• Discussion of risk/benefit/nature of the operation with patients and families in the setting of informed consent.

• Communication with the surgical team. While a “Time-out” is performed before every invasive procedure or operation, the communication ideally begins much sooner (i.e. with anesthesia re: anticipated need for antibiotics, blood products, etc, with scrub/circulating nurses regarding nature of the operation, needed equipment/suture etc).

• Transition of patient care, i.e. “sign out”

• Communication with consultants and nursing staff

• End-of-life discussions

5) Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

(a) compassion, integrity, and respect for others

(b) responsiveness to patient needs that supersedes self-interest

(c) respect for patient privacy and autonomy;

(d) accountability to patients, society and the profession; and,

(e) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

(f) high standards of ethical behavior, and

(g) a commitment to continuity of patient care

6) Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

7) Technical Skills

PGY-2 residents will learn essential clinical skills in the evaluation and treatment of EGS patients. Time spent in the operating room in a critical part of training, regardless of whether or not one is “doing” the operation. During the PGY-2 year, you will function as the operating surgeon for many cases. In some cases, the Chief Resident may function as a teaching assistant with faculty supervision. PGY-2 residents should also strive to participate in “Chief Cases” (i.e. sick, complicated patient in which the Chief Resident functions as the operating surgeon with the faculty member assisting.)

Operations/Procedures included in the SCORE curriculum likely to be encountered by the EGS PGY-2 include:

Diagnostic Laparoscopy Exploratory Laparotomy Open drainage of abdominal abscess Incarcerated or strangulated hernias Open and laparoscopic cholecystectomy Open and laparoscopic appendectomy Laparoscopic CBD exploration Partial and subtotal colectomy Muscle and lymph node biopsies Debridement for necrotizing infections

Pancreatic debridement Pseudocyst drainage procedures Open and percutaneous tracheostomy Open, laparoscopic and percutaneous gastrostomy Repair of duodenal perforation Partial gastrectomy Enterolysis Enterectomy Ileostomy Colostomy

 

8) Education

Sign out and communication the most important parts of an EGS day, the morning report system allows for patient sign-out, case assignment, debate, and time for instruction. are critical with restricted work hours to ensure appropriate continuity of care. In order to provide additional educational benefit, it is expected that all members of the team be prepared to discuss patients, physiology, and surgical options, appropriate to his/her level of experience. 

source: vanderbit

experienced vs inexperienced

-Keep an eye out for data that conflicts with schema, or which indicate plan isn’t working

This is the sign of an experienced provider, inexperienced people are so happy they came up with a plan that they tend to fixate on it, and don’t accept new data that says their plan is wrong. That’s why new officers and residents need to be watched like hawks. They will tend to push a plan through, even though new data is indicating the plan is not working. It’s not just experience, but ego. Experienced leaders know that things go wrong, and you have to adapt. Inexperienced leaders think changing the plan is an insult to their ego (which is fragile as a new leader anyway) and try to  make reality adjust to the plan, not adjust the plan to reflect reality.

New awareness

The challenge is to keep our eyes, ears and hearts open and tuned in to the incredible interactions that we encounter daily.

Did you ever have the feeling that each day was just like the one preceding it and that tomorrow will be little different? Although our days are characterized by singular events involving patients, procedures, meetings, conferences, rounds and so on, they can blend together without our ability to appreciate the variety that can lead to excitement and creativity. Perhaps this repetition (the “Ground Hog Day” phenomenon) is the ultimate reason why we need vacations to break the “sameness” that may be the basis for the stress in our lives.

In thinking about the repetitiveness of this cycle, it occurs to me that we should be challenged to ask ourselves three vital questions at the end of each day. For years I frequently challenged the medical students and surgical residents to make sure they asked themselves the question, “What new piece of information did I learn today?” Although factual knowledge about disease processes is important, perhaps this question is of secondary importance and ultimately nonsustaining. So what are the real questions?

Question 1—for reflection at the end of the day should be “What surprised me today?” When I awakened this morning, what event or experience was I not anticipating? Obviously for surgeons, the surprise may take the form of unanticipated pathology in the operating room or the unexpected challenge of a patient’s diagnosis.

The real essence of Question 1, however, is to gauge the effect of any unexpected interaction with another person, either positive or negative. Did the comment of a patient or colleague elate or disappoint us and, if so, did we incite the surprise comment or action? If we were surprised during the day, did we react appropriately and in a manner that would make us proud should we encounter the same event tomorrow, next week or next year? There are many events that are not anticipated throughout the day. Perhaps we are too distracted to remember these isolated events, but reflection at day’s end will be rewarding.

Question 2—“What moved or touched me today?” As physicians, we have great opportunities to interact in activities that are both heartwarming and heartrending. How did we feel when we talked to our patient about the maximally invasive operation that he was going to experience? Did we understand the emotion and life-changing experience of the mother with two small children when we introduced her to her breast cancer diagnosis? Did we appreciate the struggle and pain experienced by the postoperative patients who passed us in the inpatient unit as we made rounds?

Novellas could be written about the experiences and interactions that we fail to appreciate each day. The challenge is to keep our eyes, ears and hearts open and tuned in to the incredible interactions that we encounter daily. Here, some note taking at day’s end would be advantageous since even the most poignant encounters or life-changing experiences may become lost if not chronicled. At the end of a full day, we may have difficulty discerning those fleeting moments that really enhanced our day. The very act of keeping a journal and giving answers to these first two questions will give future pleasure, insight and solace as we peruse our notes and reflect on these experiences at a later date. It might be a revelation to relive those events that moved us and perhaps changed us as a human being.

That brings us to Question 3—“What inspired me today?” What did I witness that made me really appreciate my choice of a career or push me to develop a new thought, activity or even different life direction? This is really the ultimate question. This is really why I want to get up in the morning and have the desire to repeat the exercise tomorrow, next week and in years to come. Was I inspired by my work in the OR? Was I inspired by my rounds with students and residents? Was I inspired by the Grand Rounds presentation or discussion at Morbidity and Mortality Conference, and did these discussions challenge me or create a new awareness?

Yes, each day can feel repetitive and unrewarding unless we make the effort to appreciate and chronicle those special moments, thoughts and encounters. We live in a rich and complex work environment and we should make the most of it. At the end of the day, ask yourself these three questions. You will be surprised to hear the rich and rewarding answers that are forthcoming.

Do it all, have it all

Maggie Aderin-Pocock, MBE, is a space scientist and communicator, who builds instrumentation for telescopes intended, she says, “to look to the edge of the universe”. Marie Curie (1867-1934) was a Polish-born, double Nobel-winning physicist and chemist. The first person to describe the nature of radioactivity, she discovered the elements polonium and radium.
I’d known for years that Marie Curie was the first woman to win a Nobel prize—and is still the only woman to win two—but it wasn’t until very recently that I learnt about some of the challenges she faced. Her husband and collaborator, Pierre Curie, died when her children were still quite young, and she found being a working mother so hard that her father-in-law had to step in to run the household. And then there was a bit of a scandal because she began writing love letters to a married man. When I first found out about all this I thought: “That’s not the Marie Curie I knew”—but in fact I liked it. It made her more human.
Before that, I just assumed that Curie did it all. That’s the story we often get told: that high-achieving women are just brilliant, they’re superwomen, they do it all, they have it all, and they have no difficulty in supporting it all. But the fact that Marie Curie clearly did struggle resonates with me: child care for me is often a challenge, and my 15-month-old daughter often comes to work with me. Role models should be real people; if you have a role model who is, or is perceived as, a superwoman, then people think, “Well, that’s not me, I can’t aspire to be that.”
I find her attitude inspirational, too. She was a dedicated and systematic scientist, and spent long, long hours in the lab. As an experimentalist you need that. Some people think that scientists go into a lab, make a discovery, and come out with a Nobel. But success takes years and years of attention to detail, doggedness and stubbornness: and that’s what Marie Curie put in.

The benefits of being a physician will come to you only when you stop expecting them.

The doctors of tomorrow

Jerome David Salinger died a few weeks ago at the age of 91. The famously reclusive author who chronicled the fictional exploits of Holden Caulfield and the precocious Glass children last published a work of fiction in the mid 1960′s. For the past 40 years he has lived an anonymous, unassuming life in New Hampshire. I mean can you imagine an author/artist/actor at the top of his game in this day and age suddenly withdrawing from the public eye, never to be seen again? Rumor has it that Salinger never stopped writing, that his private archives contain volumes of unpublished material.

I’ll get this out of the way in the beginning—I’m an unmitigated devotee of J.D. Salinger. I’ve read everything he ever wrote, multiple times. There’s something slightly embarassing about that fact, I realize. Especially at my age. At the beginning of Hemingway’s “The Sun Also Rises”, Jake Barnes describes how Roy Cohn read a book called “The Purple Land” too late in life and was corrupted by its sentimentality and romanticism. Many say the same about Salinger’s “The Catcher in the Rye”. You’re supposed to read it when you’re a teenager, so you can identify with the adolescent angst and sense of betrayal that dawns on a young sensitive soul when he realizes the world is full of selfish phonies, but then you move on, to richer, more nuanced literary takes on human existence. It isn’t meant to be a book for a mature sensibility; if anything it can be dangerous to read it when you’re into your twenties. I gently disagree. It’s a soulful, meaningful book that I plan on reading many more times before I die. I read about Holden Caulfield and Franny and Zooey and Seymour and all the other Glass children for the first time when I was 23 years old. I was living in my mom’s basement, working at a lousy plastics factory during the day, waiting to find out if one of the medical schools in Ohio would accept me. I wasn’t exactly feeling too enthusiastic about my future prospects. My friends had all seemingly moved on in life, consulting jobs and grad schools and such, while my life had stalled for the first time. Reading Salinger that year kept me sane and hopeful I suppose. When the phone call came in the early summer announcing that I had been accepted, I drove around like a madman, happy and delirious, sort of like Holden at the end of the novel, crying in the rain as he watched his little sister Phoebe spinning in circles on the Merry-Go-Round in the park. I couldn’t exactly articulate why I was so happy, at that point. I had been chosen was all I knew. Chosen to embark upon a life of service and honor. And all that jazz. I think all medical students start out that way, wide eyed and humble and full of idealistic hope. But it doesn’t last; life rolls on and consumes you and the next thing you know you’re anxious about grades and AOA status and what specialty to pursue and which residency program to apply to and all these things that have nothing to do with Phoebe on the Merry-Go Round. Without losing those moments of inchoate happiness completely, a young doctor has to somehow figure out how he’s going to go about fulfilling his promise to himself, his profession, and his patients. How should he go about being an actual doctor? With what mindframe ought he to adopt? Ecstatic joy is no match for the cruel grind of actual existence, the years on top of one another, the petty torments of human aspiration. You need a more enduring strategy.

There are talented, intelligent college students right now across this country considering whether or not to make a run at medical school. Nowadays, it isn’t the slam dunk decision it used to be. If you were smart, top ten in your class, Dean’s List— medicine automatically went to the top of the list of possible career options. It had prestige. It payed well enough and possibly even better depending on what specialty you chose. It made your parents proud. It represented a low risk path to legitimacy in life, an assurance that your social standing wouldn’t be contingent on such factors as personal relationships or fluctuations in the business cycle or mere chance. It just seemed to be a smart, conservative thing to do for an otherwise intelligent, hard working youth who harbored vague aspirations of “helping people”.

Things have changed. (Not entirely; you’re parents will still be proud of you.) But medicine isn’t necessarily the default career pathway for a new generation of hard-working, intelligent Americans. Frankly, I don’t know why anyone would want to pursue a career in medicine anymore. It’s a tough gig, one that has lost luster over the past ten years. The pay isn’t what it used to be— there are pediatricians in this country who earn less than high school athletic directors. The debt one must take on to pay for medical school (close to $200,000) is simply absurd. And the prestige has correspondingly dropped. At some point in the near future, the local doctor will be perceived as a mere civil servant, a health provider who is seemingly interchangeable with other providers like nurse practitioners and physician’s assistants and whatever other iteration of primary care develops in the future. And then there’s the mentality in American medicine that errors and bad outcomes are unacceptable. We have “never events” now. Doctors order tests not to identify diseases necessarily, or to search for an unidentified source of a patient’s discomfort, but rather to cover themselves from any future accusations that they “didn’t do enough”. There’s an antagonism that has crept into the doctor-physician relationship, prompted by our corrupt medical malpractice system, unreasonable patient expectations, and physician cowardice and detachment that threatens to permanently blacken the soul of our profession. It’s sad and depressing for those of us young enough to know we will have to wade through this transition phase for the next 25 years. For those who haven’t committed yet, who stand on the brink of life with all its possibility and glory shining before them, medicine starts to seem far less appealing than other choices, even to the idealists.

But don’t let the negative discourage you too much. Let me tell you a secret: this is still the best job in the world. And not because I’m a surgeon and get to do “cool procedures” and occasionally get to directly affect the course of a patient’s life through a timely intervention. I like that part, don’t get me wrong. I’m not some sort of Marcus Aurelius Stoic saint unperturbed by the dramatic viscissitudes of life, possessing such powers of self restraint that I refuse entirely to pat myself on the back occasionally. I’m only human. But when you do this long enough, you start to realize that whatever good you did for that patient, some other surgeon did just as well in the town next door, and if you weren’t on call, whoever was would have done exactly what you did. You did your job, that was it. It wasn’t about you. What you realize soon enough is that when you save someone or cure them of cancer, the lucky one in the transaction is you, buddy. Anyone can cut out a colon cancer. A million surgeons can do it with sufficient technical excellence. So don’t go getting all high and mighty about it. You did your job as well as you could, based on your training and experience. No one would expect anything less. The patient would have been served just as well at another hospital.You are the one who ought always to feel privileged—that a patient would give herself to you, open her heart and soul, bare herself in all her failings and infirmities and suffering to this stranger who struts into her room in a white coat with all the answers and an indecipherable plan to somehow heal her pain. The sudden intimacy of the encounter is enough to stop your heart if you don’t watch it. The trust and the view that our patients grant us is an incalcuable gift. We see humanity in these unvarnished, stripped down moments of vulnerability. Your gaze upon the stricken is a rare glimpse into the depths of what it means to be human. I like to think sometimes that heaven is all around us, if we look hard enough. I see it in my daughter every morning, standing in her crib in the morning dimness with those deep dark eyes of hers, looking up at me, the nascent beginnings of a smile forming in her lips. But too often we miss it in our everyday dealings. We miss it entirely, consumed as we are in our silly strivings and pronouncements and righteousness and posturing. We miss it all. But in the doctor-patient encounter, there is no averting of the eyes. You must look, gaze upon the wretchedness. Maybe you can close your heart off to it, forget what you’ve seen once the encounter ends, treat it as some detached clinical experiment, a problem to be solved empirically. For some, that is the only way to avoid involving themselves too emotionally in their patients. Regardless, open hearted or closed, you can never forget the things you see and hear and touch. It burns itself into your soul. It is the great Gift bestowed upon a physician. I wrote once about a little old lady who hid a giant fungating melanoma from her family for years as she ministered to her dying husband and how she finally broke down, opened herself up and asked for help. Those moments in my office discussing what had to be done with her and her daughters will never fade from my memory. The piercing brittleness of existence surges to the forefront of your consciousness. The things you will see. The worried, raccoon-eyed mothers in the ER with their young children right before surgery for appendicitis. The elderly husbands who dutifully sit by their intubated wives for hours in the ICU. The way a family will turn a hospital room into a shrine to the grandmother resting in bed; pictures from a foregone time when she was hale and hearty, hair a different color, crazy little scribblings from elementary-aged grandkids, fading bouquets of flowers, the rows of cards. The joy in the post operative waiting room when you tell someone everything went well, your wife is fine. The eruption of relief when you inform a woman her biopsy was benign. The quiet courage and resolve in the quivering, red-eyed visage of a woman told she has breast cancer, the husband who autonomously squeezes her hand white. The 22 year old guy who screams bloody murder when you lance a tiny boil and the old Korean war veteran who tells you about an old girlfriend he once had in Oklahoma the whole time you drain his giant perianal abscess. Broken hearted lonesome single middle aged guys who tell you not to worry about calling anyone after surgery; there’s no one to call anyway. The physical maladies are no different than what you read about in textbooks. But the tapestry of human failings and strengths and triumphs you will experience as a doctor are not described in any textbooks I know of. Perhaps they are portrayed in art or literature, but the thing about art— you never know quite to believe if it is real or not, that small nagging doubt that perhaps it’s all made up. The reality of subjective experience– it’s all yours for the taking buddy. All of it is yours to observe, to learn from, to acquire. The entire spectrum of humanity on display, unadorned, vulnerable and full of absolute trust that you will do the right thing. Fear and joy and sorrow and pain and doubt and weakness reside within us all, to varying extents. You will find yourself through your experiences over a career. In Seymour, An Introduction, Seymour Glass tells his brother Buddy that all we ever do is go from one little piece of Holy Ground to the next. When you walk into a patient’s room, the holy grounds open up endlessly before you. Respect where you tread.

And that’s the catch. You cannot betray this gift of the Gaze. You must never forget that being a doctor is not about you. It’s not a reward for getting good grades and working hard and volunteering at the local hospital. No one cares what your grades were. That AOA plaque on your office wall is meaningless to the suffering souls who come to you seeking solace. No one cares about your fellowship or that you went to Harvard or about your giant research endowment. It isn’t about being president of your local medical society and making speeches. It’s not about you. You owe your patients this Spartan-like self-denial. The benefits of being a physician will come to you only when you stop expecting them.

But how do you do this? How does one adopt the proper attitude necessary to handle the burden of the Gaze? What is the process? Is there a secret? How do I avoid letting it devolve into some voyeuristic sideshow? Well I think the answer is pretty simple once you get down to it. Salinger, I think, articulates it perfectly and succinctly with his admonishment to, whatever it is you’ve chosen to make your life’s work, “do it with all your heart” and to do it for the “Fat Lady” who lives in the hearts of all men. But more on that later. First, I wanted to veer off course for a minute with two stories; one about my Aunt S. and the other about this mentally retarded developmentally delayed(MRDD) young man I saw in the hospital hallway the other week. Bear with me, please.

First, the young man. I was cruising through a long hallway on my way to the ICU, reading my patient list as I strode, when I noticed him out of the corner of my eye. He was in a wheelchair and he was washing or polishing a handrail that ran the length of the hallway. An elderly volunteer was watching him. At first I had the reflexive, complacent feeling of pity— awww, look at the poor retarded man forced to do demeaning work in public. But I stopped further down the hall. I turned and watched him for a bit. He was sort of slouched over and his mouth was gaping and he frankly looked a little wild-eyed but he was completely focused on the task at hand. He had a rag in one hand and some sort of cleaning agent in a bottle between his legs. Very meticulously he would spray a little of the solution onto his rag and proceed to carefully wipe down the segment of railing to his right. This was drab, yellowed old railing. It would never look fantastic. And it was interminable, extending far down the length of the hallway, which curved ahead to the right so from his position you never knew when it would end. But dutifully he wiped the two foot segment in front of him, even the back side facing the wall which no one would ever see. He didn’t skip areas. He wasn’t careless. He concentrated. He did a fine job. There wasn’t anything demeaning about it at all. Feeling sorry for him just disrespected his efforts. All work is worthy when done with the clean, humble, simple state of mind of the pure-hearted. It doesn’t matter what it is. Taking out a gallbladder. Paving a highway. Cleaning a toilet. Polishing a unpolishable railing. It’s all the same. We all have our opportunities to match the efforts of that young retarded guy. As doctors we’re no different. It’s easy to just go through the motions sometimes, to zip through an exam, to cut off a patient who rambles on about an unrelated topic during an office visit. But you can’t do that, at least not with any sort of regularity. Every patient we see, every surgery is just another small segment of never-ending hallway railing to be polished as well we can, with all our hearts.

My Aunt S. was an amazing woman. She wasn’t famous or renowned or anything. She was just a very loving, loyal, dedicated woman who constantly put the needs and desires of others above her own. She was always someone’s biggest fan. Once she was on your side, you had an iron willed supporter for life. She was one of those people who, if something really terrific or fortunate or wonderful happened to you, she would be unconditionally happy and excited for you. There were never any strings attached. The older you get, the more you realize how rare a human trait that is. The majority of people are unable to feel such pure and unadulterated joy for the triumphs of someone else. Too often the moment is tainted by jealousy. It isn’t that you aren’t happy for that person. You are. But a small part of you sort of wishes such good fortune were happening to you instead and an incorrigible voice deep within will whisper things like “oh, she just knows the right people” or “his parents were able to pay for all his schooling” or “she’s just about the luckiest son of a gun I know”. The majority of us succumb to covetousness and an overly competitive drive to have all the happiness in the world for ourselves. My aunt was different. She could feel and internalize the joys and victories of another person as if they were her own. The moment I remember most about my Aunt S. was my medical school graduation day. My crazy family had all made the long trip to Toledo for the ceremony and of course they all got there late and had to settle for seats way high up in the rafters. I remember being next in line, waiting for my name to be called so I could walk out across the stage to get my diploma and already there was a commotion coming from somewhere back in the crowd. I couldn’t see because it was so dark, like looking into a murmuring abyss. And then I was announced and there was this eruption of screaming and yelling from somewhere in the rafters. It was so loud and crazy and tumultuous I remember seeing parents in the front rows laughing amongst themselves. But one voice stood out. I distinctly remember hearing someone screaming “way to go Jeffer!!!!” My Aunt S. had always called me Jeffer, ever since I had been a little boy. Specifically, I heard her strident, exuberant voice above the cluttered din of screeches and yells. I turned to that spot up in the rafters and waved into the darkness, smiling like madman the whole time. Two years later she developed a lump in her breast that turned out to be cancer. A couple years after the mastectomy, the disease recurred. She battled for another year or two and then she started to deteriorate. She died two years ago this March. Now I wasn’t such a wonderful nephew to her. I didn’t call her on her birthdays. I didn’t even know when her birthday was. I never bought her gifts. I never looked to her for worldy advice or professional guidance or anything like that. I was her only nephew though and she loved me in a way that I can only now truly appreciate.

These two stories best illustrate the two aspects of “doing something with all your heart”. It’s a delicate fusion of an almost dispassionate utter seriousness, as if what you were doing was the most important thing in the world no matter how banal and tedious it seems, along with an exuberant joy in seeing someone through a period of illness, a joy that transcends anything that has to do with you. One of my favorite passages in all of Salinger is from Seymour, an Introduction where Seymour writes to his brother Buddy about what it takes to be a great writer. The advice could apply to anyone, no matter what your career aspirations. So forgive me a little poetic license to paraphrase old Seymour in doling out some words of wisdom to all those young peope out there who are contemplating pursuing their life’s work in the field of medicine:

When you die and the Man up in the sky reviews your oeuvre, do you know what He will ask you? One thing he won’t ask is how many honor societies you were a member of, that’s for sure. He won’t ask how fast or fantastic of a surgeon you were or how marvelous of a diagnostician you were. He won’t care about your awards or diplomas or honorariums. He won’t ask if your patients loved you or just sort of respected you. He won’t ask if you were nice to all your co-workers and colleagues. He won’t ask how many medical missions you went on or how many indigent patients you treated. I mean, those things are nice and all and certainly worth aiming for. But He won’t ask you about those things. You’ll get asked two things and two things only: were all your stars out and did you practice medicine every day with all your heart? That’s it. It doesn’t get any more complicated than that. So to all of you thinking about venturing off into this holy profession you better make damn sure your skies are clear and your stars are shining bright. Keep your eyes peeled for that secret and mysterious Fat Lady who lives deep in the souls of all men— she can be quite beautiful. And listen close for the exuberant scream of unconditional joy and love coming down from the rafters of your own lives….

His mantra was: We don’t read the textbooks, we write them. Just try it! Tom Scalea
“What do we have?” Ledgerwood
Every single day, is to always do what is right for her patients. Dr Blackstone

A case can get a little scary, and you keep your cool, stay ahead.  Then it gets really scary, and you must be even cooler.

Reminds me of the beauty of a universal skill. Like Mayer here, a surgeon can make it happen with any team, anywhere in the world.

Don’t start something you can’t finish.

With much practice and concentration comes a chance to perform beautifully.

Concentration, precision, and endurance

Simple, complex, beautiful work.

Precision takes practice. Performing takes guts.

Discipline. Work ethic. Instinct to go where the action is.



Doing good for your senior, doing right for the patient!

ethical and moral imagination
http://laurentledoux.blogactiv.eu/2008/09/15/should-you-develop-your-imagination-to-be-ethical-as-a-manager/

surgical personality
surgical life
art of living

defining moments
respect in a world of inequality

history of surgery, an illustrated book

Second face of power, the soft power

Soft power lies in the ability to attract and persuade. Whereas hard power—the ability to coerce—grows out of a country's military or economic might, soft power arises from the attractiveness of a country's culture, political ideals, and policies.

Hard power remains crucial in a world of states trying to guard their independence and of non-state groups willing to turn to violence. It forms the core of the Bush administration's new national security strategy. But according to Nye, the neo-conservatives who advise the president are making a major miscalculation: They focus too heavily on using America's military power to force other nations to do our will, and they pay too little heed to our soft power. It is soft power that will help prevent terrorists from recruiting supporters from among the moderate majority. And it is soft power that will help us deal with critical global issues that require multilateral cooperation among states. 

Power is the ability to influence the behavior of others to get the outcomes you want and there are several ways one can achieve this: you can coerce them with threats; you can induce them with payments; or you can attract and co-opt them to want what you want. This soft power- getting others to want the outcomes you want- co-opts people rather than coerces them.^[3] It can be contrasted with 'hard power', which is the use of coercion and payment. Soft power can be wielded not just by states but also by all actors in international politics, such as NGOs or international institutions.^[4] It is also considered the "second face of power" that indirectly allows you to obtain the outcomes you want.

"a country may obtain the outcomes it wants in world politics because other countries – admiring its values, emulating its example, aspiring to its level of prosperity and openness – want to follow it. In this sense, it is also important to set the agenda and attract others in world politics, and not only to force them to change by threatening military force or economic sanctions. This soft power – getting others to want the outcomes that you want – co-opts people rather than coerces them."^[5]

Soft power resources are the assets that produce attraction which often leads to acquiescence.^[6]Nye asserts that, “Seduction is always more effective than coercion, and many values like democracy, human rights, and individual opportunities are deeply seductive.”^[7] Angelo Codevillaobserved that an often overlooked essential aspect of soft power is that different parts of populations are attracted or repelled by different things, ideas, images, or prospects.^[8] Soft power is hampered when policies, culture, or values repel others instead of attracting them.

In his book, Nye argues that soft power is a more difficult instrument for governments to wield than hard power for two reasons; First, many of its critical resources are outside the control of governments; Second, soft power tends to “work indirectly by shaping the environment for policy, and sometimes takes years to produce the desired outcomes.^[9]” ^[10] The book identifies three broad categories of soft power: “culture,”“political values,” and “policies.”