Taking stock of surgeons' integrity and vitality: why the "three A's" no longer tell the whole story.

In her commentary ‘‘A Fire In Our Hearts: Passion and the Art of Surgery,’’ Dr. Eva Singletary calls on faculty surgeons to share our inspiration as surgeons with residents and students. Her review of the surgical trainee recruitment and retention literature discloses an attrition rate in surgery that exceeds other specialties. What deters students from choosing a career in surgery, and why do many students who have chosen surgery change their mind, rejecting not just a particular program but the specialty as a whole? Long work hours and lack of balanced lifestyle are often cited factors, but surprisingly the 80-h workweek restriction has failed to improve retention. Dr. Singletary found reports of only two interventions that helped improve surgery resident experience, and both were targeted at better management of workload. Adding physician extenders to the surgical team has been helpful in some institutions. One program described success decreasing residents’ rounding time as a result of hands-on faculty instruction to improve efficiency. Most of us, whether or not we are teachers, are passionate about surgery, but most of us would also readily admit that the hopes and expectations we held for our careers have been challenged—and sometimes pummeled—by the realities of practice. These challenges can range from the anguish of failing a patient to more mundane problems such as the perennially incorrect preference card. We weather our own disappointments, small and large, as we make our way through our own 80-h or longer weeks. We have our issues, and all too often we either have little insight into them or just ignore them. By disposition, we are a group inclined more toward action than passive contemplation. This quality is adaptive in many aspects of our profession, but it can be a liability when a good dose of introspection might serve our psyche and our relationships better. The motto in my residency was the Nike athletic wear admonition ‘‘Just do it!’’ This helped power through a scut list but did little to bridge the conceptual divide with our colleagues in the ER. It did not help us find a spouse or know what do with the feelings of inadequacy or helplessness in the face of the 7-year-old whose younger sister shot him in the chest, the depressed 80-year-old who tried to take his life jumping off a 100-ft bridge and inexplicably survived, or the conscientious, pleasant anesthesia resident who was a bit of a loner and was found dead from an overdose in his call room one morning. The prospect of a surgeon articulating passion for our work other than a little chest-thumping (‘‘Gee it’s great to be alive!’’ and ‘‘Nothing beats doing a great case!’’) is frankly a little hard to imagine for many people. If surgeons are expressive, it is much more common to overhear complaints about lousy reimbursements, lengthy operating room turnaround times, the indecipherable computerized medical record, the surgical horror story that pits the surgeon’s wits and will over patient’s poor protoplasm and bad luck, or the perceived threat to our very well-being posed first by Hillary Clinton and now by Barack Obama. How often does anyone walk in on a surgery lounge conversation in which surgeons are sharing what we value about our work or extolling our good fortune? We share our trials and tribulations, but how many times in the last 5 years has any one of us had an informal, heartfelt conversation with another surgeon that included sharing thoughts about the intrinsic rewards of our work? What does our work mean to us? How did we mature through our training to be prepared to shoulder tremendous responsibility for our patients, to be decisive and technically proficient in a crisis? How did we learn to be good listeners even for difficult patients and colleagues? When as a senior resident I had my turn to present at grand rounds