2017 Vascular Surgery Graduation Address
Given by Dr. Ron Dalman, June 23, 2017
What does it mean to be a vascular surgeon?
Thank you all for joining us this evening for this joyous event. We are here to celebrate the accomplishments of our stellar graduates, Drs. Andy Lee and Tiffany Wu, and reflect on what this year’s experiences add to the lexicon of our educational program. Thanks are especially due to the families and significant others of our graduates, many of whom are here tonight to support their son/daughter/husband/wife/father as they cross the finish line of graduate medical education. Yes, Virginia, there is life after surgical residency and fellowship!
We also want to thank Drs. Sri Seshadri and Mary Hawn for their continuing support of our clinical and academic missions. We could not maintain such a robust and effective training program without the help of our hospital and school of medicine leadership, respectively, and their commitment to vascular surgery is very much appreciated.
For my portion of the program tonight, I’d like us all to reflect on what it means to be a surgeon, and the importance of the total care of the patient.
My remarks are inspired by the memory of our prior fellows and colleagues Drs. Kevin Casey and Weesam Al-Khatib, and how they worked together to ensure the well-being of their patients under unique and extremely trying circumstances.
When the severity of Dr. Al-Khatib’s terminal illness became apparent, midway through his final year of training, the responsibility for our entire service, now managed by four fellows and one senior vascular resident, fell solely on the broad shoulders of Dr. Casey. And when I updated Dr. Casey as to Dr. Al-Khatib’s situation, and need for months of continuous solo clinical responsibility while his colleague recovered from his grueling and prolonged treatment, Dr. Casey’s simple answer was, “no problem”.
I have often though about those trying months of 2010 and 2011, and what inspired Dr. Casey to perform so well under those conditions. Dr. Casey’s concern for Dr. Al-Khatib’s well-being was always apparent and genuine, however, his selfless shouldering of his brother’s clinical burden was larger than that – he stepped up to fill Dr. Al-Khatib’s shoes in part because he knew that his colleague would be concerned about the well-being of his patient in his absence, and in that small way, Dr. Casey could lift Dr. Al-Khatib’s burden ever so slightly, in the only way he knew how.
As most of you know, we post our graduates case numbers on our website, and our case volumes match up with those of any peer program in the country. Regardless of what the future holds in store for medicine in general, surgery will fundamentally always be about technical skill in the service of the greater needs of the patient – sometimes operative, and if so, then “shock and awe” – bold, decisive, definitive - but the experienced among us realize that the practice of surgery is often more circumspect and measured.
Certainly for a ruptured AAA, with a patient in extremis, we need to rely on our anatomic knowledge, confidence gleaned from deliberate practice, and clear understanding of the goals of the procedure to swiftly intervene to save a life. Not much contemplation required in that situation, beyond the decision itself to operate.
Much more often in surgical practice, however, operative intervention is one piece of a larger puzzle. A shining example is the improvement we have noted in the management of patients with limb threatening ischemia in coordination with the Advanced Wound Care Center, under Dr. Chandra’s capable guidance. Making a differential diagnosis of abdominal pain in the elderly patient with a 5-cm abdominal aortic aneurysm – is the aneurysm symptomatic, or is the patient suffering from a concurrent gastric cancer? Deciding on thrombolytic therapy for patients with thrombophilia – age, risks, expected outcomes, alternatives?
My program director in surgical residency, Dr. Kai Johansen, described the well-trained surgeon as “an internist who can operate”.
As surgeons, we rely on our observational skills to ensure the best outcome – ready, aim fire, rather than ready, fire, and then aim. My presentation at the Vascular Annual Meeting (VAM) in San Diego earlier this month underscored the futility and frustration of chasing research clues based on imperfect information regarding the underlying pathophysiology - about how success in translational research, like in clinical care, depends on careful clinical observation.
This year on the Vascular Surgery Board, I’ve been writing questions on critical care, trauma, peri-operative management, reflecting on the evolution of our specialty – now 80% catheter directed, image guided intervention, mostly outpatient. Moving towards same day EVAR as discussed at VAM. This is a tremendous change over the last 20 years – inpatient to outpatient, with much less responsibility required for the non-operative care of the individual patient. Vascular Surgery today would be unrecognizable to the residents of the 80s and 90s – my generation and that of many of my vascular faculty colleagues.
And other specialties are adapting to these changes as well. This year at Stanford, Interventional Radiology is initiating its own “integrated” training pathway, bundling diagnostic and interventional radiology into a single experience. From their perspective, based on their approved program requirements, sufficient surgical perspective can be gleaned from a rotating surgical internship. Will an internship provide sufficient disease-focused training to educate the vascular specialist of tomorrow?
Based on my 26 years in practice, I am confident that an internship will always be just that; an internship. Mastery in Surgery will always require a far more nuanced perspective on health and disease. It is essential for all of us to remember that even though the procedures we perform are shorter, and our service census in the hospital much smaller, that the vascular patient remains fundamentally the same – fragile, compromised, vulnerable, and deserving of the full spectrum of care that we, as complete vascular specialists, can and should provide. Surgery is a calling – we should respect and honor the lessons we have learned from the many patients who have trusted us with their care.
So the take home message, for today’s graduates, as well as tomorrow’s, is that success in surgery, as in life, comes from developing the deepest possible understanding of every situation’s opportunities and challenges – and the courage to act decisively on well-founded insight. We owe that due diligence to our patients, society, and the generations of surgeons who have come before us. Weesam Al-Khatib, John Porter, Gene Strandness, and the many other role models I’ve been privileged to know in my career would expect no less.
Best wishes to Tiffany an Andy in all their endeavors, and thanks to everyone for your continued support of Stanford Vascular Surgery.