On being a happy surgeon.

This article is adapted from an address that McQuarrie delivered to the Minnesota Surgical Residents Society on June 15, 1999, as he was honored as the society's Surgical Alumnus of the Year. A somewhat longer version of his address appeared in the January 2000 issue of The Cutting Edge, a newsletter published for the Department of Surgery at the University of Minnesota (UM) Medical School. Dr. McQuarrie is a professor of surgery, a former vice-chairman of the Department of Surgery at the UM Medical School, and a former chief of surgery at the Veterans Affairs Medical Center in Minneapolis.

You won't find the address happysurgeon in cyberspace. There's no Web browser that will direct you to happiness on the Internet of Life. The medical Web pages flood you with dismal omens about the future of medicine, liberally balanced with unrealistic technologic promises. The human element in the pursuit of happiness is not on the 'Net. You have to define and find happiness yourself, with a steady effort and in an ethical way. Happiness is built on subprograms of your own strengths, accomplishments, and talents.

My own self-image is that I'm a young, irreverent, happy-go-lucky surgery resident locked up in a chubby and aging body. Despite the level of dignity that age, academic titles, and management responsibilities impose on us, I have tried to keep my inner child alive--always curious, a bit playful, and looking to tomorrow. And I am happy.

I wish that I could shed a happyvirus that would infect you with the pleasure and privilege I have felt for 40 years. But the best I can do is look in my rear-view mirror and share with you a dozen pedestrian platitudes painted on road signs I've passed that I have found to be reliable guides on my unpredictable but happy career path.

Road sign #1: Change is inevitable

You can't design a predictable career trajectory. Change will always be with you. The skill set you have just worked so hard to master will last only a few years. Let me illustrate the pace of change by comparing two generations: my father's and mine.

My father earned his MD degree at the University of California at Berkeley in 1919. Following graduation, he shared offices in San Francisco with two older physicians. The American College of Surgeons was then 6 years old and was regarded as the affectation of a few Chicago and East Coast surgeons. The hot antimicrobials were Dakin's solution and mercurochrome. A cholecystectomy was a big deal.

In 1925, my father moved to an isolated outpost in central Utah. There wasn't a consultant or a hospital within an 8-hour drive. My father knew he was in for a lifetime of self-education, so he bought every good textbook that he could and he learned as much as possible at every medical meeting. As a matter of necessity, he also built his own infrastructure. He had a local nurse set up a small operating room and two convalescent beds in her home, for which she received compensation. He learned many complex procedures by reading books and by extrapolating established general surgical techniques. His practice covered all aspects of medical, obstetric, and surgical care.

He embraced new procedures. He built a 10-bed community hospital and later expanded it to 20 beds. He made rural maternity care safe. He became a skilled urologist, and he chaired the state medical society's ethics committee. Each week he had five or six major cases. In a typical day he had 20 office visits, delivered a baby, and then made house calls. He was worked hard by an adoring but poorly paying community.

I was swept into surgery as a teenager during World War II when my father chose me over an alcoholic physician to assist him. I learned much about surgery, but not at his knee; I learned by holding a retractor or thumb sponge. My father taught me about the prudence, confidentiality, and responsibilities that are essential in an ethical practice. He also taught me to develop interests outside of medicine as a way of increasing personal happiness and satisfaction. He wisely counseled me to have at least one avocation that is less strenuous than my vocation. Unfortunately, he himself learned this only after he had become crippled and could no longer either practice medicine or enjoy his favorite outside pursuit, geology.

In his later years, he was delightfully astounded by the advances I was learning in medical school: thoracic surgery, vascular surgery, the embryonic beginnings of heart surgery. I worked with Dr. Russell Nelson in his new cardiac surgery laboratory at the University of Utah. Later I met Drs. Richard Varco and C. Walton Lillehei at the University of Minnesota when I visited during my senior year of medical school. Dr. Owen Wangensteen found the right glint of eccentricity in my eye and signed me on.

Road sign #2: Truth can be elusive

Some of the medical truth of today will be the nonsense of tomorrow--and vice versa.

After 2 years of residency, I went to Dr. Varco's lab to work on a new advancement: transplantation. After a year or so, I was drafted into the Navy and assigned to an administrative position at the National Research Council. At one meeting of its transplant committee, I got my courage up and presented my Minnesota lab work on nitrogen mustard immunosuppression as a means of promoting the survival of skin homografts. I was roundly excoriated by the pompous immunologists and geneticists there. They preached that transplants involving non-identical humans or animals invariably doomed the recipients.

By the time I left the Navy and returned to UM, the skeptics were forced to change their tune. Surgeons began to find success with purine antimetabolites and with antilymphocytic globulin, developed by an upstart ex-football player named John Najarian. He and others were rendering the earlier defeatism passe.

A word about the original Minnesota Prince of Change--Dr. Wangensteen--to show how unpredictable and elusive the development of a final answer can be. Dr. Wangensteen burned a lot of energy--his and his residents'--in his ultimately unsuccessful attempt to defeat peptic ulcer disease. He had us suck out gastric juice, titrate the acid, and calculate secretory rates. We studied what increased these rates and what decreased them. We resected, divided, and denervated the stomach in a multitude of ways.

Dr. Wangensteen knew that digestion slows at lower temperatures. This led him to test gastric cooling and, later, gastric freezing in an attempt to destroy gastric secretory cells. Picture 10 or 15 beds on old Station 22 with a shivering patient in each, next to a humming refrigeration unit. When Dr. Wangensteen finally demonstrated that freezing did indeed reduce gastric excretion, the resulting national press attention was massive. However, as the technique became widely exploited by others, it was found to be ineffective over the long term. We had developed a humbug, when what we should have done was find a bug. Dr. Wangensteen frequently said, "What the world needs is a good 5-cent idea." I'm sure that he and many others of the time would be chagrined to know that a 5-cent idea--that most ulcers are caused by a bug (Helicobacter pylori)--would have saved them a great deal of time and effort had any of them identified it.

New ideas will always shift the scenery on your life's stage. Some of you are already in winning research enterprises, and others of you will arrive at a dead end. We just don't know which is which right now. There's a saying: "Half of what I now know is not true. The problem is, I don't know which half."

Road sign #3: Honor your commitment

When you undertake the care of a patient, you are committed to that patient. Get to know your patients so that you never operate on a stranger. Surgeons don't have 9-to-S days and 40-hour weeks. The nature of surgical disease guarantees an irregular schedule and workload. Irregularity is not difficult to manage if you are honest with yourself and your family. Your hours of departure and arrival can vary. Meal times need to be flexible; there is nothing sacred about having dinner at precisely 7:00 p.m. True professionals subordinate their personal schedules to their patients' needs.

Road sign #4: Schedule family time

When you want to do something with your family, schedule it. Arrange for coverage well in advance, and keep your spouse fully informed. Make your call schedule fit family needs when possible.

Road sign #5: Don't do it for the money

If you want to get really rich, surgery isn't the racket for you. Yes, your income will eventually place you at a level where you have at least two cars and a nice house, and you will be able to send your kids through college, although with a bit of strain. You will even be able to afford one "big deal"--that is, a boat, a plane, a summer cabin, or a winter condo. But you won't be able to afford them all.

To increase your earnings, you will generally have to trade more of your leisure time. Or you can sell out and become a managed care executive; then you can have a 24,000-sq.-ft. home on the lake, draw $15 million a year in salary and stock options, complain about greedy doctors, and then write contracts to squeeze them even further.

But no executive or administrator has the basic skills and knowledge to do the simplest surgery, and all the "guidelines" in the world cannot cover the heterogeneity of disease patterns in individual patients. So focus on the real objectives of medicine.

Road sign #6: Intangibles are half your pay

It isn't money that motivates surgeons to go to Guatemalan jungles, African villages, and Asian rice paddies to care for desperately ill people. What other extra coins does the intangible paymaster give to a surgeon that are withheld from the average man? I can name seven just for starters:

* Intellectual challenge

* The opportunity to provide a needed and significant service to your fellow man

* Contact with patients and their families in a healing and treating role (you share a bit of every patient's life experience)

* The pleasures of research and discovery on the edge of change

* The continuous renewal of your enthusiasm by training younger associates

* The pleasures of interchange with highly educated, sophisticated peers--both younger and older

* The challenge of high-precision motor-manual demands

Road sign #7: Don't be embarrassed

Never feel embarrassed about your long years of training, about working hard at a highly skilled profession, and about being well compensated for it. You have cleared a lot of hurdles, and the world will always recognize you as one of a select few who have met unique academic and clinical challenges. Most of your richer corporate friends will envy the useful substance of your life. Many would gladly trade places with you.

Road sign #8: Read or perish

If you don't continue to read, you'll never cut it. Regard ignorance as a new opportunity for your intellect. Master new skills. Read a new text. Take a new skills course. You cannot expect the Internet to give you more than a smattering of ignorance. I regard it as the kudzu of intelligence.

You can read at four to five times the rate of speech. The purpose of lectures and conferences is to refine the process of analysis, not to transport bulk information. Keep studying the developing knowledge of basic surgical science.

Road sign #9: Learn from others

Try to learn from the efforts and mistakes of others. (Tip: You don't have to experience every possible mistake yourself.) Much of your surgical knowledge can be called "experiential." It is stored somewhere in your visual cortex, deep centers, and motor cortex. It defies words. This is something managed care executives cannot grasp. It brings to mind Fats Waller's great statement: "If you don't know what jazz is, man, don't mess with it." He learned what went into a virtuoso performance by listening, trying, practicing, and refining sensory and motor skills with an added fillip of creativity and intellect.

Learning to play a musical instrument and learning to perform surgery can be arduous. But enough practice and effort will eventually lead to a basic level of mastery. As it is in jazz, improvisation is demanded in surgery. A new surgeon should visit other surgeons and observe them whenever possible. Learn their jazz riffs.

Road sign #10: Teach others

The mastery of surgery provides you with an opportunity to share with others--particularly, medical students and

residents. You will be a bigger winner than they are. My continual contact with students and residents keeps me pumped up. Supporting an educational enterprise is where I get most of my pleasure. And with young trainees around, you can't get away with being a stuffed shirt.

Road sign #11: Cultivate referrals

Surgeons rarely get referrals from other surgeons. Surgeons get referrals from family practitioners, internists, pediatricians, and--this will surprise some--nurses who know them and recommend them to their neighbors and friends.

Most referring physicians don't watch you operate. They judge you on your verbal and written responses, on your attention to service, and on your complication rate. There should also be some beneficial fallout from your many personal teaching contacts.

Answer consults promptly. Write crisp, legible orders and lucid, concise consult notes. Be punctilious in your followup, and respond to calls with a good-natured attitude. All these practices will pay off. Image and substance go hand in hand.

Road sign #12: Be a good spouse

Nearly 45 years of marriage qualifies me as something of an "expert." My marriage and my family are the largest contributors to my personal happiness. My wife not only supports and challenges me, but every morning she puts me in my uniform, hands me a baton, pushes me out in front, and makes me think I'm leading the parade.

If you are married, don't take it for granted. Work at it. In my view, male surgeons in particular tend to make difficult husbands. They often have an autocratic manner and harbor strong opinions. They are competitive by nature, and their work can make them a bit hardened to the misfortunes of others. Male surgeons in particular need to develop a softer side and a good bit of emotional empathy. It is good around the house, and it is good around patients.

Don't expect your spouse to scrub in for you. By that I mean that surgeons too often expect the same obedience and service at home that they get in the operating room.

There are conflicts in every marriage. Try to develop some nondestructive mechanisms to deal with them. The rich, warm companionship of a long marriage doesn't develop without years of communicating and negotiating. Many marriages fail after a few years, and the couple's only shared experience was the selection of the major appliances.

If you're lucky, your marriage will outlast your surgical career, and when you retire, you'll be--like me--a happy ex-surgeon. Which is the best you can possibly hope for.

Acknowledgment

The author thanks Mary K. Knotterud, PhD, for her help in preparing the original address for publication.