Respect

Respect is the cohesive element in the caring and understanding for someone that binds us all together. Respect is the great opportunity for enhancing the human being. Respect is an uplifting event of unique and expanding proportions.

Respect is the engine that supports human behavior. Without respect civilizations would crumble. Individuals, therefore, require respect to maintain society's interactions. The surgical world is not that different from society. Surgeons work and live within the norms and principles of respect. Respect for their fellow surgeons, for the operating room personnel and environment, and, of course, for patients and hospital activity is essential.

Through the years, respect has not always been well practiced in the confines of the operating room and particularly with regard to the function and supervision of surgical residents. Let me be more specific. Surgeon teachers not infrequently demand efficiency and exactness of surgical residents in performing the operating act. I believe this is a good teaching practice. What is not good is to overuse the teaching capacity and exert unneeded demands from residents and fellows who are learning how to operate. What is not good is to categorize some residents as unfit even before working with them. What is not good is to create an atmosphere of tension during surgery that helps no one and adds one more burden of uneasiness for the learner. Let's then be conscious of the function and value of teaching and offer respect for residents and co-workers alike, during and after the operating act.

A young surgeon in training, Peter Svankel, was commiserating about his performance in room 14 of a respected Midwestern regional hospital, where he was helping Dr. Richard Versad, the well-known and noted academic surgeon who at the sunset of his career wanted to demonstrate his dogmatic and intransigent personality. “Any movement I take, anything I will do, he will oppose or have a negative or derogatory comment about,” Peter said to a fellow second-year surgical resident. The other resident, who had scrubbed with Versad before, clearly supported Peter's laments. “If it would be of some help, I can tell you that Versad takes the same attitude towards most of the residents, particularly when they are foreigners, and especially from third-world countries,” he said. “How is that possible in the twenty-first century?” Peter could not comprehend how Versad would act that way and still be tolerated. Lack of respect and consideration permeated the whole enterprise, overruled human understanding, and remains evident in many surgical operating rooms around the country. Even though this is a fictional example, it closely represents the current experience of many residents.

Just three decades ago, in the early 1970s, surgical residents, such as myself, regularly faced one, two, or more Versads in their academic training. Respect for surgical residents ranked low in good surgical programs, which prized surgical knowledge and practice. The surgical humanities and professionalism as a whole were low priorities, if they were priorities at all. Things have changed today, have they not?

So respect represents an essential condition for surgeon training. “Respect is the objective, unbiased consideration and regard for the rights, values, beliefs, and property of all people” [[1]]. To accept and preach respect is our responsibility as human beings and as professionals directly involved in the nurturing and development of our respective careers. Having respect for someone means caring for this person, understanding his/her philosophy of life, being considerate in the interpretation and appreciation of his/her work. In essence, to be respectful is to understand who we are and how we react and function [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]].

Respect comes in many guises: respect of an individual, society, institution, or government. Respect of laws, family, school, or work conditions. Respect at work of fellow employees, superiors, and subordinates. Respect of minorities, the weak, the disabled, as well as of the strong and governing class. Respect should be for everyone and everything. One could easily say, practice respect and you will receive it back with praises. Respect can build bridges not dreamed of before. When we lose the perception and practice of respect in our lives, we lose our communication and closeness with others, whether colleagues, family, or co-workers. It does not matter, we have lost contact with our surrounding and supporting world!

Another type of respect, as important or more important than those previously mentioned, is the respect for ourselves. Self-respect is intrinsically related to opportunities for a successful and productive life. Self-respect is not a moral requirement, but it is a moral necessity. Self-respect is the most important moral duty according to the eminent German philosopher Immanuel Kant (1724–1804) [[2]]. He explains, “Just as we have a moral duty to respect others as persons, so we have a moral duty to respect ourselves as persons, a duty that derives from our dignity as rational beings. This duty requires us to act always in an awareness of our dignity and so to act only in ways that are consistent with our status as an end in ourselves and to refrain from acting in ways that abase, degrade, defile, or disavow our rational nature. That is, we have a duty of recognition of self-respect” [[2]].

We need, then, to enhance our self-respect in order to fulfill our most essential moral necessity and, according to Kant's well-respected philosophical concepts, to fulfill our moral duty. Other philosophers [[2]] concur with Kant by reaffirming the importance of self-respect and its implications on social, political, and moral grounds. It is clearly apparent that individuals and organizations need self-respect to maximize their function and sense of worth in society.

The recognition of respect as an important quality for all people is well documented in the world of letters, philosophy, and science. Confucius (551-479 BC), a Chinese philosopher and reformer, said, “Respect yourself and others will respect you” [[16]]. James Howell, a noted writer, conveyed, “Respect a man, he will do the more” [[16]]. Cicero (106-43 BC), the extraordinary Roman thinker, advised, “He removes the greatest ornament of friendship who takes away from it respect” [[16]]. John Herschel (1792–1871), prominent English mathematician and astronomer, indicated, “Self-respect is the cornerstone of all virtue” [[16]]. In the same way, a Spanish proverb proclaims, “If you want to be respected, you must respect yourself” [[16]]. Ralph Waldo Emerson (1803–1882), an eminent American philosopher, summarized very well our thinking on surgical training, “The secret of education lies in respecting your pupil” [[16]]. Many other quotations celebrate the value of respect, but for today, we shall content ourselves with these.

Now, let us return to the surgical arena, where staff surgeons, surgical residents, surgical nurses, and the rest of the surgery personnel are freely integrated into a full and complete surgical team. Respect is elemental for any team that cannot function without everyone's participation. Respect is needed from each one of the team members. If one fails, the team will not show the congruency and efficiency so much desired for its effective function. Respect needs to be encouraged and be brought to the forefront of the surgical scene.

We do not have many well-documented examples in the annals of surgery that reflect the way respect was approached. However, patient respect was transparent in the writings of the father of medicine, Hippocrates (460-377 BC) [[17]]. With Galen (130-200 AD), several centuries later, we do not encounter a similar approach, directly or indirectly, to that of the Hippocratic writings [[17], [18]].

During the Middle Ages, surgeons did not follow or express the path of respect for patients or other surgeons [[18]]. It was not until the greatest Renaissance surgeon, Ambroise Paré (1510–1585), that respect for patients was revived [[18]]. Respect for colleagues and disciples was not mentioned in a demonstrable manner. Many other surgeons of great esteem followed, and in spite of their significant surgical contributions, they were not necessarily oriented towards the humanistic side of surgery. Respect lagged even as surgery progressed [[19]].

In the nineteenth century, few surgeons were evidently attracted by the teaching and practice of respect. One who did recommend complete respect for patients was Johan von Mikulicz-Radecki (1850–1905) from Breslau, at that time part of Germany but today in Poland. Unfortunately, he was “a ruthless master to his collaborators” [[18]]. Sadly, then, no consideration of respect for associates or trainees was contemplated. Mikulicz had been a disciple of Theodor Billroth (1829–1894) [[18]]. Did the indifference to respect become a trend, followed by surgeons in the treatment of their trainees, which persists to our time?

At the dawn of the modern age of surgery, William Halsted (1852–1922) of Hopkins fame, occupied a place of distinction in the surgical world [[19]]. His principles and recommendations were highly respected. How he respected students, residents, and colleagues is not completely recorded. However, from the prodigious pen of the New Orleans surgeon Rudolph Matas (1860–1957) [[20]], Professor Halsted emerges as a kind and courteous individual even though seriousness, calmness, and shyness were indelible marks of his personality. We see the noted Baltimore surgeon as offering respect for his surgical team, in and out of the operating room, a great quality for the pioneering specialist, something that should be emulated by future generations of surgeon masters.

In contemporary times, as recently as fifty years ago, while a fresh high school student in Mexico, I had the great fortune of participating in the operating room with Dr. Victor Manuel Romo Ruíz, a distinguished surgeon who was highly respected by all in town. He exuded competency, but most of all demonstrated a deep, caring respect for everyone attending the surgical act. He was the great example students were searching for, the professional we wanted to be associated with, the extraordinary human being we needed to keep in mind. During my medical schooling in Mexico City at the National Autonomous University of Mexico, I became impressed with another outstanding surgeon and teacher, Dr. Gilberto Lozano Saldívar. He would attend academic patients at Juarez Hospital every morning and teach medical students and residents the highlights of surgery. He was a caring and especially gifted human being. He highly respected all members of the surgical team, he appropriately praised to lift morale, and he made everyone feel an important part of the team. It was unfortunate that the earthquake of 1982 in Mexico City put an end to his caring and productive life.

In the 1970s, I was a surgical resident at a great American medical center in Minneapolis, the University of Minnesota. I learned a great number of very unique ideas and concepts about surgery. I was exposed to the best teaching and most advanced operative experience. But I realized as well that some mentors were more interested in showing respect to members of the surgical team than were others. Surgeons who lacked respect created an uncomfortable environment for everyone in the operating theatre. Under these conditions, residents became the most vulnerable group, followed thereafter by the scrub nurses and surgical technicians. How to teach surgery and remain respectful? How to operate well and not lose your temper? How to face adversity during surgery and react with equanimity? How to be a good surgeon and above all be a good and respectful human being? These are the genuine and fundamental thoughts that should guide today's surgeons. Most importantly, how can we teach respect to faculty, residents, and nurses alike within the operating room boundaries?

Certainly we can start by recognizing the presence or absence of respect, by documenting lapses, by praising those who practice respect, and by offering educational and tutorial support to those who do not. Several ideas come to mind, such as establishing seminars, developing randomized videotaping that clarifies acceptable and unacceptable behavior, instituting role playing between residents and practicing surgeons, and finally, incorporating surgical resident advocates, who will exercise fairness to all involved, into surgical residencies.

In the coming weeks, I challenge you to be aware of the various circumstances in which, by observing respect, you can make a difference in the field of surgery and in the many individuals who practice this noble profession. In closing, respect is the cohesive element in the caring and understanding for someone that binds us all together. Respect is a great opportunity for enhancing the human being. Respect is an uplifting event of unique and expanding proportions.