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At last, I have arrived at that pinnacle category of a surgeon’s career—to be considered a “senior surgeon”! It has taken 48 years of surgical training and practice to achieve this “lofty” title, and now I can contemplate the full perspective of my career from surgical intern to this point in my professional life.
It is important for me to acknowledge at the outset that I am greatly indebted to all of my mentors, educators, colleagues, friends, family, faith, and, most importantly, my patients, all of whom have shaped my career and my contributions to the profession of medicine. As one of many senior surgeons who continue to remain clinically active, I hope the following reflections may represent some common opinions of my experienced colleagues.
Have I become a better surgeon as I have gotten older, and how do I view surgical procedures at this point in time? I have come to understand that there is a balance between experience and technological advances, as well as how eagerly I approach recommending surgery versus conservative therapy. As a young faculty surgeon, I looked upon disease states as a “challenge” for my surgical capabilities, and I was considerably more aggressive about recommending surgery than now. Through experience and an increasing awareness of patient self-determination, I am more likely to accept a patient’s declination of surgery, given that I have adequately explained the risks,
benefits, and other treatment options in plain language they can comprehend. I want the patient to fully understand what they may be facing with a surgical procedure, and allow them to ask questions in order to arrive at their autonomous decision. What senior surgeons can offer to patients and resident physicians is a broad perspective of disease and treatment that comes from years of experience, trial and error, and judgment. I also appreciate the importance and richness of the patient–physician relationship now more than ever.
I am often asked, “When should a surgeon know it is time to retire?” I believe this is based on many factors—cognitive function, physical conditioning, manual dexterity, judgment, self-awareness, continued altruism, and the strength of love for medicine. Senior surgeons who can maintain the reliability of the above factors have a great deal to offer the patient, the profession, and medical education. Keeping the body healthy and capable is a fundamental requirement for a surgeon, so I am all about exercise, and always have been. Learning for a surgeon is indeed a life-long affair, and while head and neck anatomy does not change much, everything else about otolaryngology-head and neck surgery, as well as medicine in general, is in a constant state of renewal and discovery. The brain must be stimulated, and I have found over the years that working with medical students and resident physicians generates a keen sense of stimulation for my knowledge acquisition.
The brain must be stimulated, and I have found over the years that working with medical students and resident physicians generates a keen sense of stimulation for my knowledge acquisition. —Richard Holt, MD
At this point in my professional career, I am not as interested in performing surgery as the primary surgeon as I am in teaching surgery to trainees. I like nothing better than to ask questions when staffing a resident surgery, challenging the resident surgeon to consider “what ifs” and “what is the pathophysiology and anatomy of this condition,” or drawing diagrams and illustrations on the sterile sheets that I think will help explain how to perform a certain step in the surgery; I am a very visual surgeon. I have always enjoyed surgery as a “group effort,” and my own enjoyment comes from stimulating and encouraging the resident surgeon. If I can impart a few teaching points as I staff a surgery, then I feel relevant and helpful.
But, while I do enjoy assisting a resident surgeon, I would not staff a procedure that I did not feel I could personally complete successfully and safely should the need arise. I am more likely now to not select very complicated surgical cases that I feel would be more appropriate for a younger faculty colleague to add to her/his surgical experience. I have “been there, done that” sufficiently that I am very happy to give them the experiences I have already collected. Also, they are very good surgeons, and the patient will be in excellent hands!
The joy of medicine and otolaryngology–head and neck surgery. I have studied the recent phenomenon of “physician burnout” and contemplated how I have successfully avoided this condition. It is important to acknowledge that I firmly believe I was “called” into the practice of medicine at a young age and have never, ever regretted my path. For me, faith and the profession of medicine are inextricably linked in a sense of social responsibility to others and with an obligation to care for sick patients for as long as I can do so safely and with adequate knowledge.
I often teach the lesson that only medicine and religion deal with the hard realities of death and dying, particularly with respect to helping individuals and their families face serious health challenges. Having studied both religious ethics and secular ethics, with an emphasis on bioethics, I have come to realize that physicians are stewards of the human body, including the mind and emotions, and that is a tremendous responsibility that requires humility, honesty, respect for persons, compassion, and ethical behavior.
I have personally had outstanding role models for these professional qualities over the course of my career, and I feel a strong sense of obligation to “pay it forward” to others. We each must honestly acknowledge that we did not succeed in our careers on our own, but through the efforts of many well-meaning mentors and role models who shaped our professional capabilities. Paying it forward also means stimulating medical students to seek the proper specialty that fits their own personality and capabilities, whether or not it will be otolaryngology-head and neck surgery.
The practice of medicine is enriched by outside interests. I have been favored over the course of my career with a great number of colleagues, mentors, trainees, medical students, and especially patients who have informed and shaped who I am as a physician. This informed journey for me started in elementary school and continues to date. And, I have been especially blessed with a loving, supportive spouse, who is also a physician, and who shares my philosophy about how special our profession is. We were married while we were in medical school, and because of time and finances, waited for eight years to start our family—our first child was born while we were on active military duty and cost us $5.76 for the delivery! I acknowledge that all medical marriages/families face many challenges, and it was no different for us as we began our medical careers in earnest, and now, three children and eight grandchildren later, it still remains a challenge, albeit much easier.
I wish I could proudly state that, in my early to mid-career, I was a full and equal participant in the efforts of raising a family, but that would not be honest. I did my best, but it was still an unequal balance much of the time regarding family responsibilities. I have tried hard to make up for that imbalance over the years, but will always be indebted to my wife for her understanding and hard work on behalf of our family.
So, the love of medicine and otolaryngology, the stimulation of teaching, the rewards of patient care, the camaraderie of my colleagues, and the richness of my family life have all contributed to a wonderful career and an avoidance of physician “burnout.” One additional factor in my own life bears comment, and may serve as a suggestion to young physicians. Not only are well-rounded family and professional lives fundamental to a satisfying career, but so is the diverse stimulation of the mind across a wide range of outside interests. I have been stimulated by my military career, which has added a dimension of world-view realities and opportunities to practice in austere and dangerous environments. I have seen terrible injuries, and also acts of courage and self-sacrifice, enhancing my belief that even in the worst of situations, the human spirit can shine through.
My own interests in aerospace medicine, NASA, bioengineering, bioethics, and religion have expanded my intellectual capacity and provided experiences far beyond the usual otolaryngology practice. I have traveled the world, engaged with various cultures (which has assisted and informed my current diverse practice), and had experiences that could never have been foreseen by a boy growing up in rural Missouri in the 1940s and 1950s. These experiences are also part and parcel of my teaching in medicine, as so many things in life are inter-related and worthy of sharing. I believe it is important for senior surgeons (as well as all physicians) to be constantly stimulated through a variety of experiences, and to seek broad knowledge in diverse subjects that can inform us as citizens of the world. I am thankful to be a senior surgeon but realize that category comes with a “time limited” stamp.
Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio. He writes the column “Everyday Ethics” for ENTtoday.