Ruth Armstrong: The right attributes

A LEADER in surgical thinking and innovation in 13th century Europe, Guido Lanfranci, is credited with describing the following characteristics of a good surgeon:

“It is necessary that a surgeon should have a temperate and moderate disposition. That he should have well-formed hands, long slender fingers, a strong body, not inclined to tremble and with all his members trained to the capable fulfilment of the wishes of his mind. He should be of deep intelligence and of a simple, humble, brave, but not audacious disposition. He should be well grounded in natural science, and should know not only medicine but every part of philosophy; should know logic well, so as to be able to understand what is written, to talk properly, and to support what he has to say by good reasons.”

You might think this is a tall order, but here, over the past decade, the Royal Australasian College of Surgeons has been working on an even more comprehensive set of nine core competencies for surgeons that go far beyond technical and cognitive skills, each with three “attributes”.

The strength of Fellows’ and trainees’ endorsement of the importance of each of these professional competencies and attributes was put to the test in a study published in the MJA, and reported in our first news story.

While differences in the generally high level of support for all the competencies and attributes were small, when tallied and ranked the authors said their findings showed “a clear gap between the prioritised importance of technical expertise, communication, professionalism and medical expertise compared with health advocacy, and management and leadership”, suggesting “an emphasis on individual skills rather than on achieving a common goal”.

It could be argued that these small differences do not matter — surgeons don’t work in a vacuum and can draw upon the skills of their colleagues such as anaesthetists, without whom competent, safe surgery is not possible.

But the study authors argue that in order to practise their craft in today’s complex world, surgeons do need comprehensive skills in collaboration, teamwork, management, leadership and advocacy.

A report released last week provides an example of the need to see surgical excellence in context — in this case, the context of increasing global inequity in access to basic life and livelihood-saving procedures: a topic that has been somewhat neglected in the global health discourse.

The Lancet’s Global Surgery 2030 Commission found that five billion people worldwide, particularly in low- and middle-income countries (LMICs), do not have access to safe, affordable surgical and anaesthesia care; that only 6% of the 313 million procedures undertaken each year occur in the poorest countries where more than a third of the world’s population lives; and that those in poverty who do access surgery often face “catastrophic” costs.

It also said providing basic surgical services in LMICs is affordable, saves lives, and will lead to economic growth, and that the provision of such care should be an integral component of health systems worldwide.

Browsing through the report I came across an obituary for one of the 25 commissioners who had been involved in producing the impressive body of work, who had died shortly before its publication.

Edgar Rodas was an Ecuadorean surgeon who spent many years going by donkey, or on foot, to remote highland villages where his quest to provide surgical care was often impeded by a lack of infrastructure. He eventually was able to convert a truck into a mobile operating theatre to provide basic surgical care to many people who would otherwise never have had access to it; a work that survives him and has been extended by a charitable foundation.

When asked to describe Rodas, his colleagues came up with the following: “… humble; an attentive listener; very quiet and very unassuming; he loved talking with people; he was kind and gentle; a well-organised man with an eye for detail; he collected data and analysed it to show that his work was good; he would say, ‘Don’t let anyone tell you something can’t be done. There is always a way’.”

Now that’s a surgeon!
 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight