When he wasn’t disciplining his wives or warring with France, King Henry VIII had time to do a few things around the castle—like set up a department of surgery and staff it with the best barbers in early modern England.
It apparently made sense at the time, since barbers were skilled with the primary surgical tool—a knife. So, with the addition of an innocuous punctuation mark, surgery and grooming became one occupation.
When summoned, the barber-surgeons extracted teeth, removed gallstones, and amputated limbs. Conveniently, they could slice into your arm to do a bloodletting to relieve your fever and then, probably with the same knife, take a little off the top if you were up for it.
Considered beneath the skills of physicians, surgery was a commercial trade learned through apprenticeships. Then in 1559, a jousting-match injury raised the prestige of surgery after King Henry II of France took a lance to the eyeball, and it pierced the royal brain. Prominent barber-surgeon Ambroise Paré tended to the king’s injury and wowed colleagues with his innovative ideas and advanced neurosurgery tools. The patient didn’t survive, but Paré’s reputation soared, and he became known as the father of modern surgery.
This incongruous medical model was exported to the American Colonies. However, by the mid-1700s the barber-surgeons were stripped of their hyphen and relegated to shaving and haircutting. It took another 150 years or so to nail down the details of exactly who in the medical community should do what, but, by the end of the 19th century, surgery finally became the sole purview of formally educated physicians.
As the University of Rochester’s Department of Surgery celebrates 96 years in operation, a hyphen captures the essence of the department’s 21st century surgeon—the Surgeon-Scientist—skilled in performing complex surgeries, exploring novel therapies, and leading major health care institutions while preserving an “unrelenting focus” on the patient, says Department of Surgery Chair David C. Linehan, MD, who assumed leadership in 2014 and who also serves as the Seymour I. Schwartz Professor and chief of clinical operations at Wilmot Cancer Institute.
In his seven years of leading the department, Linehan has:
- doubled the surgical faculty
- garnered five new endowed professorships
- expanded the expertise in subspecialties
- advanced the use of minimally invasive procedures
- attracted millions in research funding
- established a research center making breakthroughs in immunotherapy to treat pancreatic cancer
- instituted new procedures to train future surgeons in clinical and communication skills
- improved patient outcomes
- improved the department’s fiscal health, allowing for more resources to support research and education
- established a culture of respect, collaboration and inclusion throughout the department.
It’s all part of what Linehan envisions as a “bold future,” in which the department uses its legacy of clinical excellence, cutting-edge research, and educational innovation to impress on the next generation the crucial nature of the myriad skills that define the Rochester Surgeon-Scientist.
In the most recent annual report outlining the department’s strategic goals for the next five years, Linehan capitalized two words: CHANGE and MELIORA. The connection between change and “ever better” is clearer now than it was 2,500 years ago when Greek philosopher Heraclitus opined that change is more than a part of life; it is the essence of life. Medical advancements such as immunotherapy and robot-assisted surgery require surgical wizardry achieved only by embracing change.
Resting on its laurels, Linehan says, is therefore not an option for the department. One of those laurels has been the 60-year presence of Seymour I. Schwartz, MD (Res ’57), the physician who co-wrote and edited the “surgeon’s Bible.” Schwartz’s Principles of Surgery, voluminous at 2,292 pages, has been translated into multiple languages and is now in its eleventh printing and its fiftieth year as required medical school reading. Schwartz, who died in 2020 at age 92, had chaired the department for eleven years (1987–98) and was an internationally revered surgeon.
“The program punched above its weight, with figures like Charles Rob [MD and former department chair] and Sy Schwartz. You knew you would learn to operate,” says Craig R. Smith Jr., MD (Res ‘82, Flw ’82), chair of the Department of Surgery at New York-Presbyterian Hospital/ Columbia University Medical Center.
Smith did indeed learn to operate, and in 2004 performed a quadruple bypass on former President Bill Clinton.
“Dr. Linehan has done a remarkable job keeping the program aligned with Dr. Schwartz’s vision and building on a strong hospital program and faculty,” says John Fung, MD, PhD (Res ’88), a renowned transplant surgeon and director of the University of Chicago Medicine Transplantation Institute.
Linehan keeps a copy of Schwartz’s book, the fifth edition (printed in 1989), on the coffee table in his office. The canary-yellow leather cover features a line drawing of two Renaissance-era surgeons standing over a table of crude surgical implements. As Linehan talks about the department’s direction, he taps on the book and notes that “Eighty percent of what is in this textbook is no longer true. What will it be like in another fifty years?”
When Linehan discusses the department, the word “edge” comes up often. As medical knowledge, technology, and complexity of surgery progress at an astonishing pace, edge-type thinking is vital.
An edge in Linehan’s line of sight is the one demarcating current knowledge about disease. His plan to reinvigorate the department’s status as a research “powerhouse” is working— research funding has ballooned to $9 million, a 50 percent increase over its 2015 level. The University has climbed to number 15 on the list of top research organizations, as compiled by the Blue Ridge Institute for Medical Research. Linehan’s goal is to boost it into the top 10.
“My dream is for this research funding to improve outcomes and quality of life for patients with difficult-to-treat surgical problems,” says Linehan, a well-known surgical oncologist who specializes in pancreatic cancer. “I am passionate about clinical trials. There is hope.”
Five years ago, Linehan established the Center for Tumor Immunology Research to continue searching for new pancreatic cancer treatments by deciphering the complex interactions within the tumor microenvironment. This innovative approach seeks to spark the body’s immune system to eliminate the immune cells that promote cancer progression and to stimulate the cancer-fighting cells into destroying the tumor.
“It’s another way of thinking about cancer therapy—attack the cancer cells but also reprogram immune cells to use the patient’s own immune system to fight their cancer,” says Linehan, the Center’s director.
The timeline is urgent because the five-year survival rate for pancreatic cancer remains in the single digits, though it has increased from 5 percent to a high of 9 percent.
“It’s going in the right direction,” says Center Co-director Scott Gerber (MS ’01, PhD ’05). “Based on what we know about this cancer, we are heading down a very promising path.”
The department is currently running 10 trials, several of which are from Linehan’s lab, and he hopes to increase the number of patients enrolled. Nationally, only 5 percent of patients eligible for clinical trials choose to enroll. Linehan would like everyone to join a trial.
A research lodestar is that the University contributed significantly to two of the most important advances in cancer research in the past 50 years, an “astounding” fact, Linehan says. Foundational research by URMC scientists was instrumental in developing the HPV vaccine—the first cancer vaccine—which has been 90 percent effective in preventing cervical cancer. The other advancement stemmed from studies that investigated chemotherapy-induced nausea from many angles, established anticipatory nausea as a major barrier to completing treatment, and participated in reporting the first evidenced-based recommendations for using anti-nausea and anti-vomiting drugs.
“The research is really important, having funding for research is really important, attracting the best and the brightest investigators into the field is really important, and we’ve had success in doing that,” Linehan says in a URMC video. “That’s when the magic starts to happen.”
Linehan believes that innovative research should proceed to the next step and be “impactful” by translating it into clinical trials and then shepherding it through the lengthy administrative process so that the patient benefits.
“Dr. Linehan says breakthroughs are not complete until we see them in people. It’s a different philosophy,” Gerber says. “Most research scientists are not trained to translate findings into clinical trials, but Dr. Linehan has the expertise. It’s somewhat rare to find that.”
Key to growing and broadening the department’s research portfolio, Linehan says, is pairing the researcher doing the biological investigation with the clinician aware of the patient’s unmet needs. This fusion can inform the reasons why some treatments work better than others, says Linehan, who likens his role to that of an orchestra conductor uniting the players so that “the sum will be greater than the parts.”
“As a researcher who works predominantly with mice, it’s hard to get the feeling of what the patient is going through,” says Gerber. “If you want to do good research, talk to the patient. There are people reliant on us, and it really changes your outlook.”
Collaboration is key, says Linehan. “It’s been the secret to the department’s success. Research is a team sport.”
In addition to the immunotherapy research, other current department investigations include innovative research on melanoma, nerve regeneration, minimally invasive cardiac and liver surgery, and percutaneous approaches in treating vascular disease.
To train the next generation of Surgeon-Scientists, the program encourages residents to spend one to two years conducting research by working in a lab, earning an advanced degree, or participating in the interdepartmental Surgical Health Outcomes and Research Enterprise (SHORE).
“Research is not just about the papers,” says Yanjie Qi, (MD ’06, Res ’14, Flw ’15), associate program director for Curriculum and Simulation. “You flex your intellectual powers and learn to assess science, which helps you become a better surgeon.”
Growth in the Time of COVID
Even before COVID-19 patients filled the hospital, the clinical case volume was increasing; in the past five years it rose more than 20 percent. Last year the department saw 28,000 new patients and performed 14,512 surgeries. Under Linehan, the department faculty has doubled in size to 72, a third of whom are women, and there are now 49 general surgery residents, 13 research fellows, and more than 300 staff.
Diversity has also increased, for which department members credit Linehan; culturally, the faculty represent 15 different countries. Representing the state of technology are five da Vinci robots, key tools in the department’s efforts to expand the use of minimally invasive procedures to hasten recovery time.
Linehan says that the University has been supportive of expanding the department to meet the needs of the community. Although some say that it can be hard to recruit people to the Flower City, Linehan says he hasn’t had that issue.
“People are honored to come and look at a job in Rochester,” he says. “Everybody knows that Schwartz’s department of surgery has a strong legacy of excellence.”
Attention to growth was disrupted to some degree by the deluge of COVID patients. The specifics of how the department coped with this historic medical horror are mostly known because its accomplishments, though epic, are also strangely commonplace.
The scramble to find ventilators, PPE, beds, and staff was repeated in institutions around the globe. A special emergency department, staffed with volunteers from all surgical specialties, treated nearly 2,000 patients suffering from the virus.
“It was pretty amazing. People signed up and there was no hesitancy. That speaks volumes,” Qi said.
The pandemic is far from over, and even as the viral waves continue to roll in, ripple effects remain from previous waves. The ripples are major, like ones created by skipping a boulder rather than a stone across the lake. Many elective surgeries were postponed in 2020, and staffing challenges in health care nationally that were exacerbated by the pandemic are having an impact on hospital capacity, patient volumes, and surgical schedules across the region.
As if a global pandemic weren’t enough trouble, the national violent crime rate has spiked, which similarly has caused a spike in the number of trauma patients needing surgery. URMC’s designation as the region’s only Level 1 Trauma Center and verified burn center, providing tertiary and quaternary services, means that the most urgent and complex cases in 17 counties are funneled here.
In this mid-sized city known for excellence in medicine, music, and technology, the homicide rate is higher per capita than in Chicago, typically one of the nation’s most violent cities. The trauma division reports a 25 percent increase in severely injured patients, a 30 percent increase in trauma surgeries, and a “stunning” 90 percent increase in gunshot wounds compared to last year, says Acute Care Division Chief Mark Gestring, MD. The division handles the trauma program, emergency general surgery, the Kessler Trauma Center, and Kessler Burn Center.
“The other change has been in the brazenness of this violence—middle of the day, middle of the week, kids around,” says Gestring.
In an effort to help stem the violence that brings trauma patients into the hospital, the division has expanded its efforts to engage with the community, joining with local groups to build stronger connections between the community and the organizations that serve it. It also participates in the national Stop the Bleed initiative to train bystanders in emergency procedures.
And as the region’s sole trauma educator, the division trains teams in smaller hospitals on procedures for stabilizing seriously injured patients in preparation for transfer to the Medical Center. A new “trauma truck” allows the division to offer the course at the individual hospitals so that more people can be trained efficiently.
Despite the challenges posed by the uncertainty of COVID-19’s mutated march around the nation, the department marches to the beat of its own drum: provide excellent surgical solutions, including use of 3D-printed organs and minimally invasive surgery, and improve patient outcomes. The department has the region’s only programs in pediatric cardiac surgery and living-donor liver transplant, its only nationally accredited program in rectal surgery, and the sole simulation program for robotic surgery.
The Abdominal Transplant and Liver Surgery Division offers the only liver transplant center in upstate New York. Division Chief Roberto Hernandez-Alejandro, MD, and his outstanding team have quadrupled the annual number of liver transplants—last year’s total was 103—since he joined the University five years ago. The division is also a national leader in robotic kidney transplant surgery and performs more than 100 kidney transplants and 50 complex hepatobiliary surgeries each year.
Hernandez-Alejandro has built the region’s only center for living-donor liver surgeries, which averages 15 cases per year, second highest in the state. The center is one of only two programs nationally offering liver transplants to select patients with advanced colorectal liver metastasis, a new hope for patients with nonresectable liver disease. Last year the division performed seven such surgeries. Patients from around the country seek expert advice from the division, which has added two surgeons to its team.
“My dream,” Hernandez-Alejandro says, “is for our name to mean that this is the place to come for simple liver surgery, complex liver surgery, and liver transplants.”
Currently the process for patients with advanced colorectal liver metastasis involves waiting to see how they respond to chemotherapy. Shortening that lengthy process greatly increases the chances for a successful outcome and reduces the suffering caused by the disease and the chemotherapy treatments, Hernandez-Alejandro says. He has started a consortium with the Cleveland Clinic and Toronto General Hospital to identify transplant patients earlier in the process.
“Life is hard if you are in the middle of the waiting list for a liver,” he says. “We are creating hope for patients so they can live many years more with a good quality of life.”
Of Pioneers and Giants
Although French barber-surgeon Paré would have at least scored his own castle had he saved the brain-addled King Henry II, he created a more enduring legacy by dutifully recording his astute observations and bold experiments to train the next generation of surgical pioneers. Before his investigations, the standard treatment for gunshot victims was a dousing of boiling oil on the wound. Paré found more success with a poultice of chopped onions or a liniment of egg yolks, oil of roses, and turpentine.
The Department of Surgery’s history is replete with its own pioneers who pushed past the boundaries of the known surgical world and then shared that knowledge.
“The place was chock-full of surgical giants,” says Bernard T. Ferrari, JD, MBA (’70, MD ’74), a member of the University’s board of trustees and dean emeritus of Johns Hopkins Carey Business School. “They were really superb surgeons at the top of their careers. It influenced me to become a surgeon.”
“The first time I scrubbed with Dr. Carl Andrus and watched him perform a most elegant kidney transplant surgery, I was hooked for life,” says Robert Montgomery (MD ’87), chair of the Department of Surgery at NYU Grossman School of Medicine, director of the NYU Langone Transplant Institute, and an international authority on transplantation.
“The tradition of surgery at the U of R is storied, and many of the great figures were active when I was there; they were somehow so compelling that they convinced me with their bigger-than-life personalities and dedication to patients to become a surgeon, a pathway I had not anticipated. That tradition lives on today,” Montgomery says.
The department offers residents a significant surgical experience, including training in the latest trends in robotic surgery. In addition to rotations at URMC, trainees do rotations at Highland Hospital, at Rochester General Hospital for private practice experience, and at F.F. Thompson for community hospital experience.
A varied experience is one of the department’s strengths, says Fung, the transplant surgeon at the University of Chicago. As a resident here, Fung appreciated the opportunity to do “bread and butter surgery” at the smaller hospitals before transitioning to more complex surgery at Strong Memorial Hospital.
“The operating experience was very rich, so by the time my residency was over I was a pretty good surgeon,” he says, adding that the program influenced him to institute a similar community surgery program when he joined the Cleveland Clinic.
New to the department’s training methods is a unique program that uses a combination of wet lab, dry lab, and simulation. Also new is a video review, similar to the post-game analyses common in professional sports. Trainees’ performances are reviewed, and they are given specific feedback, such as how to remove physical barriers during a patient interaction or how to turn silence into positive communication.
“We have to prepare them beyond the 1,000 cases and 80 hours a week,” Qi says. “That’s the medicine part and then there are the arts.”
There is also an art to selecting the next crop of surgeons who will continue the Rochester legacy. Since all of the applicants have similar academic backgrounds, Linehan looks for more nuanced qualities such as passion and collegiality. He personally conducts a 10-minute interview with the top 100 applicants—selected from a pool of about 700—for the seven available resident spots.
Qi notes that an applicant’s outside interests such as musicianship or athletics are important because they reveal a balanced perspective in life and a deeper understanding of the fortitude needed to overcome setbacks.
Linehan also looks for a willingness to challenge the status quo, which is a key tenet of his plan to embrace change as a pathway to innovation.
“You can’t have an answer,” he says, “if you don’t have a question.”
Not Your Father’s Surgeon
The 21st-century surgeon doesn’t necessarily look like your father’s surgeon. Surgeons were historically white men. The few female surgeons were likely to be mistaken for a nurse or an orderly come to collect a lunch tray.
Recent political events have elevated the need for improved diversity, inclusion, and equity to top priorities in the field of medicine and at URMC. In addition to its ongoing diversification efforts, the Department of Surgery formed a committee of surgeons, administrators, nurses, residents, and researchers to address ways in which it can create a more inclusive environment.
“A diverse group brings more to the table, which helps everyone in the department to grow. They bring a different mentality,” says committee Chair Hernandez-Alejandro, who trained in Mexico, Canada, and Japan.
Committee member Qi says she is in favor of moving beyond the standard PowerPoint presentation and adopting a more substantive approach.
“We want to elevate the conversation and thoughtfully introduce it, not just as an afterthought or a box to be checked,” says Qi, who credits Linehan for increasing the diversity of faculty and residents.
The committee is moving its conversation beyond the hospital walls to improve access to medicine for members of the local community. One strategy has been to visit local schools and promote the profession. “We try to motivate and stimulate young people so they understand that there is a good future in medicine for you,” says Hernandez-Alejandro.
The department’s efforts to contribute to the ongoing transformation of the gender and ethnicity of surgeons became dramatically obvious in 2017 when the first all-female class of residents graduated.
The class was perfectly timed for the April 2017 cover of The New Yorker magazine, which featured four female surgeons staring down at a patient. Five of the department’s female residents replicated the cover, contributing to tens of thousands of similar tweets sporting the #ILookLikeASurgeon hashtag.
Female surgeons recognize that, while their numbers and acceptance in the field of surgery are growing, they will still encounter those who cast doubt on their professional abilities based on their gender. Some of the women have recounted stories of patient rounds in which patients ask to speak to the male intern in the group instead of the female resident who performed the life-saving surgery.
“They are outstanding surgeons,” Linehan says of the 2017 class. “I’d let any of them operate on me.”
The AMA noted that “The #ILookLikeASurgeon movement and the subsequent #NYerORCoverChallenge demonstrate the changing face of surgery and the roles of social media in resisting the social and cultural force of long-standing stereotypes.”
Although the numbers of women and men are near parity in medical school, the AAMC found in 2018 that the percentage of women in surgery is much lower.
“A few years ago I was at a scrub sink, and one medical student said she liked surgery but wanted to have a family,” says Qi, a trauma surgeon who is married and has two daughters. “We’re still facing these age-old stereotypes. If you have a love of the OR and procedures, there are different paths,” she adds, noting that being able to choose from a variety of specialties provides options suitable to various lifestyles.
As the gender and background of surgeons change, so too does the perception of the specialty, long plagued by a reputation of the surgeon as a macho, egotistical, prima donna who hurls insults and instruments at colleagues, belittles everyone in sight, speaks brusquely to patients, and in general exhibits a toxic superiority complex. Hence the oft-repeated joke: “What’s the difference between God and a surgeon? God doesn’t think He’s a surgeon.”
Past surveys found that stereotypes persist to some degree because portrayals in television and film are embedded in the American psyche and can interfere with actual physician-patient interactions. Surgeons were typically portrayed like maverick Hawkeye Pierce of M*A*S*H, whose penchant for disregarding orders and mouthing off was tolerated not only because Colonel Blake was a wimp, but because Hawkeye had mind-blowing surgical skills and could operate on a patient while barreling down a bumpy road in the back of a Jeep. And, perhaps most of all, surgeon clichés were embodied in one arrogant, abusive, bullying, condescending, curmudgeonly, misanthropic, and brilliant television physician: Dr. Gregory House.
An article in the AMA Journal of Ethics in 2018 noted that although stereotypes are “largely a relic of days gone by,” the lingering effects will dissipate only if efforts are made.
Such perceptions appear to be changing overall. A 2019 study discovered that, in contrast to previous studies finding that patients’ impressions of surgeons were typically formed by stereotypes, surgeons were rated as exhibiting more warmth than do television celebrities, police officers, politicians, and elite athletes. While not the highest praise, it’s important because the researchers noted that “perceptions of surgeon warmth and competence influence treatment expectancies and satisfaction with treatment outcomes.”
The unflattering surgical stereotypes are outdated, says Linehan, who does not tolerate boorish, arrogant, or uncivil behavior. He says that unprofessional behavior not only jeopardizes teamwork but can imperil patient safety if team members are afraid to voice concerns to the surgeon.
“As surgeons we’re dealing with life and death all the time with people who are scared out of their minds. We tend to be exacting and demanding because we care about patient safety, but it’s really important to exhibit the highest level of excellence,” Linehan says.
The Surgeon, the Psychologist, and the Patient
The wellness revolution may seem like a bohemian plot to sway everyone toward essential oils and yoga with goats. However, the department embraces wellness because a healthy healer is a successful healer.
“We want to keep residents whole as human beings,” Qi says. “It’s not just about the operation.”
Although residents are limited to an 80-hour work week with shifts of no more than 24 hours, burnout is still a serious issue and has led to national calls for new methods of mitigation. The problem has been linked to higher rates of medical errors, depression, substance abuse, and even suicide. Some residents abandon the practice of medicine altogether.
Residency is inherently rigorous given the amount of training required, but the department believes that self-care does not impinge on learning. Rotations that are clearly unsuitable are adjusted. Time off to go to doctor appointments is built into the schedule. Problems aren’t handled with a just-toughen-up lecture. If, for example, a resident is upset about losing a patient, Qi helps them process the event and build the resilience needed to cope with the demands of surgical life. Nurturing and surgical training, she says, are not antithetical.
After two months of settling in, interns attend an orientation session and are encouraged to bring guests in person or via videoconferencing. Clinical psychologist Lauren DeCaporale-Ryan, PhD (Flw ’13), the associate program director of the department’s resident wellness program, says that interns are reassured to hear the faculty say they understand intern worries, such as feeling like an imposter. She then “onboards” families and friends by explaining the intense demands of surgical life to help them understand why their budding surgeon may not call often and how to support them by being attuned to signs of burnout or depression.
“Family relationships remain a protective factor and a resource that trainees turn to in times of stress,” DeCaporale-Ryan says.
One aspect of wellness is communication; anxiety can be avoided and problems solved if people talk to and also listen to each other. It’s a legacy thing for Rochester; graduates have always been sort of the John-Boy Waltons of the surgical set.
“I think you can tell a Rochester-trained physician in the way they communicate with patients,” says Ferrari, the dean emeritus at Johns Hopkins. “Other programs have that knack, but Rochester more so.”
“It’s a kinder environment. It’s something that makes Rochester special,” says Qi, who adds that some trainees express shock at discovering that a surgeon can be nice.
To advance these skills, the department instituted a unique coaching program to emphasize communication as a way to build collegiality and forge a closer surgeon-patient relationship. And it’s not just for residents.
“I take high performers and try to make them higher performers,” Linehan says. “Instead of coaching only the squeaky wheel, we coach the leaders, who then coach the junior faculty.”
The communication training is wide-ranging, encompassing “the basics of hello and goodbye and everything in between,” DeCaporale-Ryan says. Some people are skeptical about being asked to polish social interaction. “It feels evaluative for them; they say they hadn’t been trained,” she says. “With time, residents come to appreciate the benefits of the training as it supports efficiency and patient outcomes, and can aid in the establishment of meaningful dialogue.”
DeCaporale-Ryan says that among the physicians she has worked with, surgeons, who tend to be focused and detail-oriented, are also very willing to accept feedback. When she tells them to smile more, often they do not question it and seek precise clarification. One surgeon asked her to “just tell me for how long—how many seconds.”
The success of the program was measured in a pilot study by Susan McDaniel, PhD, in which participants rated the program at 3.7 on a scale of 4 and said it exceeded their expectations, didn’t interfere with workflow, and increased workplace satisfaction. Patient response has also been positive: “They appreciate that the institution recognizes that communication is part of the core delivery of care,” DeCaporale-Ryan says. The program’s influence is spreading; former residents have contacted her for help in establishing similar programs.
“As a department, we want people to perform to their best, to perform competently and with empathy and supportive communication. It’s not just about scientific knowledge,” says DeCaporale-Ryan.
The program’s legacy of strong communication skills has influenced other institutions around the country. Joseph M. Serletti (MD ’82, Res ’87), former chair of Plastic Surgery at URMC and now chief of Penn Medicine Plastic Surgery, recalls that his medical school interview here was unlike those he had elsewhere because he was “interviewed as an individual.” Impressed with the interview and the collegiality he experienced during his time at the University, Serletti says he created a similar model at other institutions during his career.
Montgomery had a similar experience as a medical school applicant. He recalls being “struck by how humanely the Admissions staff and faculty treated me. They were genuinely supportive of my nontraditional pathway. They seemed interested in me as an individual and the unique experiences that I brought to the school. This turned out to be a theme for my whole U of R experience.”
The emphasis on communication extends to positive mentoring, which continues to be a bedrock principle in the department. It was one of the reasons that Ferrari, the University trustee who earned JD and MBA degrees along with his MD, decided to pursue surgery. “Many of the surgeons and residents took time to encourage me when I was a lowly student. I always felt they were in our corner.”
In fact, there was a seminal moment in Ferrari’s budding surgical career when he received kind advice from Rob, a former department chair and international pioneer in vascular surgery. In the operating room, Ferrari was wearing soft contact lenses. As Rob showed him how to insert a chest tube, “Suddenly, my lens popped out and Dr. Rob grabbed it. I thought, ‘Well, this is the end of my career.’
But Dr. Rob just said ‘I recommend spectacles.’”
Ultimately, surgery is about the patient. Linehan says that “being patient-centered is baked into the model.” The department follows the biopsychosocial model of training surgeons to understand the complexities of patient needs, pioneered decades ago by University physicians George Engel, MD, and John Romano, MD, and based on the theory that biological, psychological, and social factors are integral parts of human health. The University is well known for this model, and Linehan is further embedding it into the overall zeitgeist of the department.
In clinical practice, the biopsychosocial approach encourages the physician to understand that self-awareness is a diagnostic and therapeutic tool—that patient relationships are key to providing care and that patients’ life circumstances contribute to understanding their health issues. Using that information, the physician can determine which domains are key to promoting the patient’s health.
The Biopsychosocial Model
This holistic approach diverges from the model promoted by medical educational reformer Abraham Flexner, who was focused on biological factors. “Patients were primarily viewed as serving the academic purposes of the professor . . . . Flexner’s corpus was all nerves without the life blood of caring . . . . The revisions in medical education that are now taking place are re-claiming the rightful eminence of the service component of medicine—the centerpiece of the doctor-patient relationship,” argued Dr. Thomas P. Duffy in the Yale Journal of Biology and Medicine in 2011.
“The Biopsychosocial Model really resonated with me my first year as I was just returning from a Watson fellowship studying African traditional medicine, and it provided a universal paradigm for the healer/patient relationship,” says Montgomery.
Ferrari didn’t buy into the biopsychosocial philosophy at first. “At the time I viewed it as psychiatric babble-babble, but I soon realized its power,” he says.
Ferrari remembers that Rob began post-surgery discussions with families by addressing their deepest fears. Even though the purpose of the surgery was to address a vascular issue, Rob knew that families typically worried that cancer could be discovered. When he did not see any cancer malignancies during the operation, Rob made sure to note that fact immediately.
“The first thing he would say is that there was no cancer,” Ferrari recalls. “I will always remember that.”
Smith, of Columbia University, recalls that the department always put “a high premium” on the patient. “It’s an important tradition,” he says. “If you operate on someone, you take care of them and take personal responsibility for what is happening.”
The surgeon is less effective, Qi says, if there is no understanding of the patient’s life situation and the financial and other life issues inhibiting their ability to recover and stay healthy. A patient may not be able to afford medication, so simply advising them to take it isn’t the entirety of the physician’s role.
Understanding the patient means engaging with the community in outreach efforts such as events explaining the dangers of opioid use and promoting health care as a rewarding career for youth.
“You can’t get the patient better if you just do the operation,” Linehan says. “We practice in that model. The fourth leg on our stool is community engagement.”
The World Health Organization considers community engagement a social justice issue and a critical function of health care organizations in delivering care that is “geographically, financially, and culturally accessible.”
“We will never take for granted the privilege of caring for these patients,” Linehan says. “At the end of the day, that’s why we’re here.”
A department video echoes that message, saying that the research, training, and practice exist for only one reason. Then two words pass soundlessly across the screen—our patients.