| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Editorials |
Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81, 80131 Naples, Italy
Received 14 July 2008; received in revised form 18 November 2008; accepted 19 November 2008.
* Corresponding author. Tel.: +39 0815903262; fax: +39 0815903823. (Email: Gaetano.Rocco{at}btopenworld.com).
Ladies and Gentlemen, Members and Guests,
During the last year, I took almost invariably night flights home from my trips to Europe and worldwide representing the ESTS.
I know you all have been in the same situation when, from the window seat, one looks outside and sees his or her reflected mirror image. It was no different for me, immersed as I was in the train of thoughts and some tiredness. Nevertheless, I could not help being constantly captured by the clouds and the signs of the distant mankind below. That is where I got the title for this lecture; from the effort to concentrate my attention, rather than on myself, on our common interest, trying to preserve a view from above.
I still keep the email I received from Richard Berrisford while I was a consultant in Sheffield. Two lines just to enquire whether I would be happy to be involved with ESTS as a councillor. I did not know what I was getting myself into. However you, Richard and Toni Lerut should look at what you have done and be ready to take responsibility for it.
Undoubtedly, in the last five years, general thoracic surgery worldwide has lived an era of renaissance. The major North American organizations elected two giants of thoracic surgery in Peter Pairolero and Joel Cooper to Presidency of the STS and AATS, respectively. In addition to being the current STS Secretary, Doug Wood is about to become the President of the Western Thoracic Surgical Association next month. Again, in the forthcoming future, two general thoracic surgeons without need for introduction such as Alec Patterson and Doug Mathisen will lead again the most prominent cardiothoracic organizations in the world. Furthermore, another Italian thoracic surgeon, Erino Rendina will step to a top leadership position to hold the presidential office for EACTS. I am glad to note that most of these outstanding surgeons, some being also personal friends, are ESTS members. Three of them are even Honorary Members of this society. Whatever the reason for this success of Thoracic Surgery and Thoracic Surgeons, it is a fact that, to quote a line from a famous movie, ‘with greater power comes greater responsibility’.
The past two years have been so dense of facts and emotions that I finally came to understand why previous ESTS Presidents have used in their Addresses terms such as enthusiasm, mission, allegiance, loyalty, dedication [1,2]. At some point, during their office term, each of the ESTS Presidents has delineated his own specific interpretation of the role. Nevertheless, I learned a lot from each and every one of them. In particular, I have learned that, irrespective of the personality features, the role of President of this organization takes some imagination but, above all, much adherence to reality.
I have tried to interpret my Presidency according to the principles of serving and protecting the ESTS membership in the delicate transition towards actual societal independency. In my moments of trouble, I have always resorted to a basic underlying philosophy to support the sometimes difficult decisions I had to take during the past year. I found it handy to comply with a very simple slogan, which is to preserve quality, to maintain quantity.
1. The relationship between quality and quantity in thoracic surgery
Quality is the search to define individual specificity in what we do, in how we accomplish a task; finally, what we are as human beings before professionals. We have to identify the ‘Qualis’, in its literal translation from Latin, that is, the distinctive element among similar entities. This element of distinction is so unique that emerges as a universal criterion to be adopted as a benchmark by other individuals who, in turn, may be interested in a different personal search for quality in their own terms and on their own turf.
Quality could be inherited. You may have it in your genetic traits and, yet, you are not aware of it. Indeed, quality is usually perceived as a gift, even in the surgical practice. Conversely, contemporary surgery is teaching us that quality is a steep up-hill path that anyone, with the appropriate tools, can climb. To express quality in surgery takes hard work, personal dedication and willingness to adhere to the principles of sharing with peers and transferring information across generations. Failure to follow these basic tenets could have deleterious effect, much similar to the recurrent story of the technically endowed footballer who struggles with self discipline and eventually ends up, unnoticed, scraping a living in the minor leagues. He will never be part of a winning team.
I firmly believe that the role of this society is to enlighten the path, provide the tools, and, set the standards for basic quality inspired practice. Rest assured that there will always be the ones exceeding the standards of quality, the outliers. They stand out for themselves – some have the gift. However, a functional society needs to focus on raising everybody's ability to comply with evidence-based surgery by involving the most gifted in the mentoring and steering process.
Indeed, to serve and to protect. To serve and to protect anyone, from the trainee to the established consultant, with no exceptions made because the setback of one is the setback of the system in providing guidance and support. In other words, a setback in the quality-making and ensuring process – qualis facio, qualifacio, ‘qualification’ pathway. And we must all feel responsible for that.
Professional success is often referred to as popularity among patients and peers, and it is often measured in terms of number of treated patients or, to use a common, albeit inelegant, expression, the number of ‘cases’. Several factors may concur to determine popularity, including expertise, experience and wealth of interpersonal skills. One additional element could be the availability of provision of similar care (i.e., competition) in neighbouring catchment areas, and, in the recent years, institutional or individual predisposition to ‘marketing’ – i.e., the effort to create a product or offer a service as consistent as possible with the expectations of the ones who will then use this product or service.
The size of the surgical series has become the crucial factor to evaluate the success of a professional career. Many ‘cases’ make ponderous series, ponderous series yield greater statistical power, greater statistical power leads to scientific reliability. This logic sequence still holds true.
However, with the multiplication of qualified surgeons treating the same conditions, it has become increasingly difficult to accrue, for research and quality assessment purposes, sufficient personal or institutional experience characterized by a definite degree of homogeneity in the standards of heath care management. Indeed, it is a fact that general surgeons, cardiac surgeons and vascular surgeons are performing general thoracic operations in Europe and that this creates a scattered pattern of practice.
The alternative for the dedicated thoracic surgeons is the resort to multicentric studies where differences in surgical approach are often underestimated in the analysis of the outcome. And yet, the majority of us forget that consistent training of young surgeons according to current national and international criteria, fierce auditing of individual and institutional data and correct interpretation of these data may render multicentric studies more reliable by evening out sometimes minor, albeit inevitable, differences in practice.
Meanwhile, under the formidable pressure of cost containment policies, hospital trusts and administrators are evaluating performances by trying to quantify institutional activities through the DRG, HRG or whatever system looking at raw, non-risk-adjusted or stratified figures. This analysis, in turn, will help justify their strategies and investments and, in some cases, eventually the very existence of a hospital unit or division.
Pay per performance strategies are being delineated based on these non-risk-adjusted figures. Our professional and personal lives, the way we perceive our future, may radically change as a direct consequence of such decisions.
In a way, it is the triumph of the ‘quantum’ prevailing on the ‘qualis’. Should it be so? Should we let it be so?
2. Regaining control of our practice
The recent literature has addressed the issue of the relationship between quality and quantity in thoracic surgery and how to implement the effect of this relationship into the routine clinical activity. Analytic tools are being developed to compare international, institutional and individual outcomes as a means of standardizing baseline parameters of performance [3]. In this setting, ESTS is currently strongly committed to designing and implementing a robust thoracic surgical database as a platform to homogenize thoracic surgical practice across Europe. Not without difficulties as the parallel experience in North America has confirmed.
The general feeling is that surgeons usually look at these undertakings with suspect, resilience, at best, with distraction. At times, ‘incentives’ to participate in database projects need to be devised. In his recent Presidential Address delivered during the 2008 STS Annual Meeting in Ft. Lauderdale, John Mayer has prospected the idea for US cardiothoracic surgeons to enter their data in the STS National Database as an integral part, almost a condicio sine qua non, of the reimbursement credentialing process [4] – http://www.sts.org/2008webcast/shows/mayer/index.html.
Nowadays, regaining control of our practice means adhering to the principles of good surgical practice without waiting for extraprofessional bodies to impose this choice on us. The following is a excerpt from Good Surgical Practice guidelines issued by the Royal College of Surgeons of England – http://www.rcseng.ac.uk/rcseng/content/publications/docs/good-surgical-practice-1 – which summarizes the principles of teamwork, risk prediction, resource assessment, and audit and data recording which are the foundation of clinical governance also in thoracic surgery.
Good surgical care starts at first consultation and diagnosis, with the patient as either an outpatient or inpatient. It is given in conjunction with other colleagues in the health care team. It concentrates particularly on the practice of safe, timely and competent surgical intervention, ensuring that patients are prioritised and treated according to their clinical need. Surgery should be avoided where the risks outweigh the benefits. The decision of intervention is assessed on the basis of the surgeon's ability and experience, patient need and available resources, taking into account the requirements of both emergency and elective activity. Surgeons must demonstrate competence in their own area of practice and a willingness to refer where necessary. They must demonstrate knowledge and understanding of the necessary ethical and legal issues relating to their area of surgical practice. They must communicate clearly with patients and their supporters and ensure that comprehensive, legible and contemporaneous records are kept of all their patient interactions.
Self-regulation should be the aim to be pursued at a national level first, but organizations like the ESTS should be attentively receptive. Truth be told, cardiac surgery has served as the experimental environment where a re-visitation of surgical practice has taken place in the name of data auditing, self-regulation, recertification and revalidation; in one word, clinical governance [5].
While working in the UK, I have witnessed the painful process suffered by our cardiac colleagues while attempting to regain control of the qualification pathway. However, under the guidance of a farsighted leadership, UK cardiac surgeons have revolutionised their practice by looking into their national mortality and morbidity figures, looking at their resources and, finally, at each other's performance. No ghost hunting but a lot of solidarity and a hint of corporatism were the necessary ingredients to a palatable recipe in a time when several entrees tasted sour and bitter.
Why is this example so important while we approach the multinational, multiethnic, multicultural Europe in an effort to standardize the way thoracic surgery is practiced across the continent? Several years ago, Walter Klepetko along with a prestigious faculty [6] took over the task of identifying the most adequate parameters, such as catchment areas per surgeon ratio, availability of human and technical resources and surgical credentials – necessary to safely practice thoracic surgery in Europe. As a result of that formidable undertaking, several recommendations were suggested; the applicability of which remains uncertain because uncertainty remains the rule of the game. In fact, the next step must be to focus on rigorous audit and critical analysis of surgical outcomes as the elements being at the core of the self-regulation process for quality control, which represents today the utmost priority.
The achievement of quality will be the driving force to get the submerged, countless surgeons practicing general thoracic surgery channelled into, almost funnelled in, a continuum of regulatory steps leading to qualification, recertification, and, revalidation. Following this model, we can smoothen the raw edges of a multifaceted specialty from which surgeons and physicians from different professional backgrounds draw each year a sufficient number of procedures to justify a job plan, an increased use of resources or simply to gain a highly acknowledged professional profile.
We need to change that. Thoracic surgical practice should encompass areas that are currently under the domain of other specialties and to include procedures to be performed in dedicated thoracic surgical departments and units. Stereotactic surgery and radiofrequency ablation, endoscopic photodynamic therapy, EBUS or EEUS staging of mediastinal involvement from lung or esophageal cancer are only a few examples of these forgotten lands. In other words, we need to control our entry gates, the airways and the upper foregut.
As a consequence, the idea is that only certified units should generate certified surgeons dealing with non-cardiac diseases of the chest. Unit certification should be obtained when the requirements are met of database construction and maintenance, periodic auditing, and satisfactory performance in comparison to national and international standards after careful scrutiny by an independent commission empowered by the European regulatory body, the UEMS, the European Union of Medical Specialists.
In a fashion similar to what happens with the faculty administering each year the European Board Exams, ESTS should offer to be responsible for creating a pool of peers and supporting them in this inspective role around European certified thoracic surgical centers.
At a national level, a strict ‘no certification – no reimbursement’ policy should be implemented. Whoever wants to practice general thoracic surgery and claim reimbursement should be in possession of the credentials obtained through a rigorously designed qualification pathway. Once we define the quality control process, it should be easier to concur about the quantitative aspects of the practice required to maintain the accreditation and meet revalidation standards; i.e., volume of procedures per units and per individual surgeon. As an example, the definition of a surgeon predominantly practicing thoracic surgery will have to be reworded according to the heterogeneity of local patterns of thoracic surgical practice (Table 1 ).
|
A new qualification process would indeed lead to a widened basis in the specialty as long as this process is the same for everybody and it is rigorously complied with. Only then the difference in the originating specialty between cardiothoracic, general surgeons, and, general thoracic surgeons would not have a reason to persist, in the name of quality and in the name of one united specialty of general thoracic surgery in Europe. The specialty served by the European Society of Thoracic Surgeons.
In the past two years, I have participated in endless discussions about the need to achieve these targets only by merging societies, mutilating organizations or altering the nature of restricted professional clubs. Indeed, the time has come to switch from the concept of a federation of societies to the idea of a federation of intentions aimed at establishing the basics of our practice and implement them in the real world. My plea to future leaderships is to give these intentions a name by identifying those individuals who can actively concur in designing the project and see it through. This is where the voices of the ones working for the actual interest and benefit of the thoracic surgical community will stand out from the background noise.
3. A crisis of thoracic surgical identity?
If quality is the search of specificity, then the concept of specificity should be clarified. From a statistical standpoint, the crucial factor in determining the overall specificity is, in fact, the false positive rate. False positive, i.e., what you may show that you are but you are not. A mistaken sense of identity, which makes distinction from others arduous. And maybe that is what renders the specialty less appealing than in the past outside Europe and so confusingly outlined within our continental borders.
What is the thoracic surgeon's identity today? A thoracic surgeon is not a statistician, but he/she is required to carefully analyze data from clinical and non-clinical sources with proper statistical tools. Not a pulmonologist, albeit the need for a thorough knowledge of the pathophysiology of respiration is fundamental for a thoracic surgeon to avoid patients being unnecessarily denied a surgical option.
The thoracic surgeon is not a gastroenterologist, despite the fact that more often than not a thoracic surgeon is consulted to draw the fine line between lifelong medical antireflux treatment and surgical repair.
In many European countries, chest surgeons are still primarily revered among the finest interpreters of the essential art of bidimensional capture of chest X-ray details. The Roman author and philosopher Horace, much before Roentgen, reminded us of the real quintessence of a human being. ‘Puluis et umbra sumus’ – we are but shadows and dust. Exactly what thoracic surgeons are used to observe on chest X-rays and define with meticulous care and unparalleled expertise.
Re-establishing our identity may also mandate a thorough revision of our surgical practice.
This could mean going back to basics of teaching, the pleasure of intuiting art in two skilful hands, as well as the discouragement in perceiving when, instead, the light is off and drawing consequences from that. Unfortunately, heavily involved in administrative tasks as they are, mentors will have less and less time to catch at least a glimpse on the gestational period of the newly born surgeon.
I believe, dear colleagues and friends, that thoracic surgery must get itself in shape. Drop excessive weight from all distracting voices, go back exercising by spending countless nights to outline the surgical strategy and then apply it in theatre with absolute technical perfection. This takes time, courage, and dedication. A minor effort compared to the need to include, among your mental habits, a critical review of what you have done with an inquisitive mind to produce an efficacious audit of postsurgical results.
For the young apprentices, all the above translates into more time in theatre observing; not simply watching; more time in the labs refining your surgical movements and more time to actually develop your personal skills also by reading and travelling to see what someone else does. Anachronistic as this plea may seem, especially with the implementation of the working time directives closing up on us, to achieve all this it might take a lot from you as surgeons, a great deal from your mentors but also a paramount effort from ESTS to put you in the position to make the most of what is available.
The definition of new professional figures, already popular in the United States, as the surgical technicians and the gradual extension of specialized nurses’ job specifications to cover routine ward and outpatient work are possible counteractive measures against the shortage of surgical training time. ESTS should gain a lobbying attitude in Brussels to include the above into the criteria for accreditation of a thoracic surgical unit. This is where cohesion with other surgical specialties and organizations must be sought to transversally increase the political impact of this perspective.
4. What patients want
There is little doubt that patients, at all latitudes, are increasingly cognizant of the wide array of options to treat their condition. I will not emphasize any further the role of the media and the world wide web in patients’ education.
What I personally see in my office is that a patient still needs guidance in the chaotic jam of available information. In evaluating a potential candidate to lung resection, the issue of a substantial mortality almost always dictates the final choice. What about the dreadful set of postoperative complications leading the patient to be bedridden, oxygen dependent, or wheezing from a patent bronchus in an empty chest? All in all, current evidence in the literature puts death second among the untoward events after thoracic surgery in patients’ opinion. In fact, they are afraid of losing independency and their financial well being with it because of escalating expenses due to their prolonged need for health care.
On the other hand, a better surgeon should be rewarded based on the ability of effecting a shortened length of hospitalization and a diminished prevalence of long standing complications requiring readmissions and reoperations – all factors affecting the overall quality of life of the patient (and the caring surgeon), inevitably impairing the perception of the received care.
Despite being used to quantify volumes and the attendant reimbursements, the DRG or HRG system can only partially represent the quality of the administered care. To complicate an already difficult scenario, the pay per performance concept is being introduced with the intention to emphasize the quality of service resulting from the analysis of common clinical indicators [7].
These clinical indicators have been investigated with a hair-splitting attitude. The results have not quenched the thirst for a balanced, evidence-based thoracic surgical practice. We are beginning to understand that to fully evaluate surgical performance we might need additional tools to better define the impact of non-clinical indicators [8]. And this is where a combined effort involving all thoracic surgical communities from North America, Asia and Europe is needed to construct homogeneous databases in order to stratify risks, design proper institutional volumes, and case-mix according to the available local resources, and, to create the proper surgical expertise provision. Examples of this evolution could be minimally invasive thoracic surgery applied to pulmonary resections or esophageal resection for cancer.
In this setting, are we moving towards teams with one or two VATS lobectomists, an esophageal/upper GI surgeon, a trachealist with special expertise in mediastinal vascular challenging problems and a reconstructive chest wall surgeon? To answer these and other questions, we ask ourselves additional questions under the form of surveys.
5. What surgeons want
The multiplication of surveys has proved contagious in our specialty as in others. Properly conducted and analyzed surveys are a resource of unprecedented value for the thoracic surgical community. In fact, the rationale behind a survey is that we should know what we want before embarking on designing the best way to get it. The final aim is to define clinical guidelines that should address our professional actions but not tell us what to do. Rather, these guidelines are meant to shape everyday practice into behavioral protocols meant to ensure error-safe clinical conduct.
The survey-guidelines scenario approximates surgeons to patients in the need for guidance through the mazes of modern medicine and surgery. Ironically, in this search for guidance, patients and surgeons are living parallel lives in a vicious circle doomed to self-maintain by enforcing each other to raise stakes in the name of an improved quality of care.
6. What women want
Possibly, the crisis of surgical identity is prompted by a gender alternation since, for many reasons, males are increasingly deserting surgical training programs. In North America, the connotations of this process are well known. In Europe, first among other organizations, the ESTS has perceived these changing times and offered a platform inside the leadership structure to understand the implications and facilitate the presence of women in thoracic surgery. I am glad to witness the enthusiasm and the dedication emerged from our women ESTS ad hoc committee, certainly among the most active in its function of advising the council on potential issues which may arise in the future. In this context, I do not see far from us the moment when one of our female colleagues will be assigned the highest ranking position among the ESTS officers.
7. Pride and prejudice. Impact factors or factors with some impact?
In the end, it all comes down to the individual's ability and predisposition to work for the society. Again, it takes a view from above. In the past, the European Society of Thoracic Surgeons has been criticized while striving to strike a balance between ethics of representation and the academic profile of the ESTS leadership. A lot of pride on our side; too much prejudice from others. Today, this controversy is solved. Certainly, in the past, our preference has gone to pursue the goal of voicing and answering the needs of all dedicated thoracic surgeons in Europe from the Atlantic to the borders, cultural and geographical, with Asia. However, a few of our colleagues in this or other organizations had realized that fair representation is not in contradiction with a highly distinguished academic reputation and the attendant international visibility.
Once again, it is just a matter of fine tuning our quality standards. In a recent commentary published in the Journal of the American Medical Association [9] Eugene Garfield, along with Irving Sher the inventors of the Journal Impact Factor, admonished against the dangers of evaluating individuals solely according to their Impact Factor, which is currently used for lack of alternatives in the emerging field of ‘Scientometrics and Journalology’.
The ESTS must select its leadership based on the perceived ability to address the real factors which may have an impact on our professional life. As the recent and I am sure future choices for councillor positions have confirmed and will confirm, an accurate identification of active interpreters of the natural mission of this society will inevitably lead to individuals who will combine international visibility with respectable impact factors. Accordingly, the old vexata quaestio ‘Quis custodiet ipsos custodes?’ ‘Who will then control controllers?’ is answered. Custodes will have to be the first to comply with individual eligibility criteria, which makes them, in turn, the authorities supervising the process of realizing into practice the wealth of ESTS innovative ideas with stringent intellectual honesty and undivided commitment to ESTS membership.
However, raising further the already remarkable ESTS leadership's academic profile may simply mean paving the way towards clarifying the role of the surgeon–scientist [10]. In future developments, which have their foundations today, research and education will be based on the understanding of biology, genomics, and molecularly-targeted therapy of the diseases and patients we treat in order for thoracic surgeons to play a major part in the consolidation of so called individualized medicine. I am confident that ESTS will be at the forefront of these changes.
8. Quality and quantity in the educational process: the relationship between societies
After almost two years since separation from the European Association for Cardiothoracic Surgery, I want to address the issue of the aftermath of this decision from the standpoint of the practicing European general thoracic surgeon. He or she has witnessed the mitosis leading to two meetings, the apoptosis of a healthy collaboration, and, the proliferation of scientific events; often a duplication of efforts. European thoracic surgeons were inundated with an educational offer which at times resulted in confusion for the absence of a well defined list of priorities. Nowadays, as a consequence, the surgeon is faced with making difficult choices to strike a balance between educational needs and study leave allotments. Let alone the time subtracted to the rightful demands from families.
I am sure all of us are aware of the dreadful repercussions of ill-devised development plans and investments with the attendant waste of resources in current health care management. While consolidating solid financial foundations by establishing a balanced relationship with Industry according to the principles recently outlined by Cerfolio and co-workers [11], ESTS is trying to fight the temptation to disseminate resources and concentrating on providing one single arena of highly prestigious educational profile: the thoracic school.
In this setting, ESTS will seek and recognize the support and input by the national bodies to coordinate regional educational efforts and prioritize events for direct societal endorsement.
Nevertheless, from this podium, I would like to invite the European organizations dealing with the diseases of the chest (especially EACTS) to consider revamping collaboration through a transparent exchange of information aimed at co-ordinating future events in the supreme interest of continuing professional education in order to avoid duplicating efforts by creating a sort of registry of events where the originality of new concepts and ideas are protected by defined rules. This should facilitate prioritizing societal endorsement of European thoracic surgical meetings. In fact, duplication of efforts invariably leads to decreased attendance and interest, and, possibly, downsized industry contribution. Indeed, industry will be forced by more limited budgets to select fewer events of interest. As a consequence, a global thoracic surgical network based on strict peer-reviewing and post-event audits to verify the appropriateness of the educational outcome is now needed more than ever.
If we really have at heart the supreme interest of the thoracic surgical community, now is the time to show this by increasing the level of interaction despite obvious differences in goals and means of pursuing them. In this setting, I see with favour the farsighted procedural steps made by other European organizations towards recognizing the unique and independent nature of general thoracic surgery by warranting the status of separate committees or divisions with dedicated resources within their own societal structure. In effecting this change, I read an implicit acknowledgement of the righteousness of the cause brought forward by the European Society of Thoracic Surgeons in the last few years.
However, this global interaction model should be implemented further. Our fellow North American societies, the AATS and the STS, have already put a similar mechanism into action when dealing with matters of general interest, such as the recertification and revalidation process, not only for the professional body but also for the general public and the media.
Dear Members, Dear Guests, I can clearly announce today that the ESTS is committed to be the think tank for European thoracic surgery. Despite its strongly rooted European foundations, I envisage that ESTS will also continue looking towards the west and the east to welcome the committed thoracic surgeon who may find, within our society, an ideal environment for his or her professional growth and the development of interpersonal friendship and camaraderie.
The ever increasing interest and contribution from non-European thoracic surgeons towards the ESTS activities make me wonder whether an ESTS powered International Society of Thoracic Surgeons (ISTS) could represent a platonic idea or the unique possibility for a real professional and educational platform for thoracic surgeons worldwide. Time will tell.
Today, at ESTS, we have definitely sailed but we run the risk to float between earth and open sea. Quantity is a solid vessel with a perseverant crew under the command of a resolute captain. Quality control will be the compass telling us where we should be heading to avoid the unknown.
This is the challenge of today. In the interest of the many who practice thoracic surgery in Europe, I invite current and future leaderships to focus on serving and protecting their fellow surgeons by preserving an unbiased view from above.
My service to you would not have been so unconditional and dedicated without the support from the ones who have contributed to my personal and professional growth and whom I feel I owe a profound sentiment of gratitude.
Quantity and quality are constant elements of the clinical practice at the Mayo Clinic in Rochester Minnesota. My advanced clinical fellowship in general thoracic surgery there has revolutionised my life by teaching me to adapt to difficult situations and make the most of my individual effort. I found myself at thinking while working at Mayo – that there was no better professional place to be. I learned in time that for sure there are others where this miracle also happens. However, the feeling of Mayo being unique and special has never abandoned me, reason by which I want to publicly thank Peter Pairolero, Vic Trastek, Mark Allen and Claude Deschamps, who is to me a special person among special persons, for making me feel part of the Mayo family. After more than 10 years, I still take huge pride and honor in this.
I feel I also owe my expression of gratefulness to my parents who are here today and the people and places that have filled my professional and personal life in the past, from Sondalo to Sheffield, and now to Naples. Over the decades of this peregrination, I would lie to you if I said I had it all planned for. However, if, as someone says, life is a puzzle, I can now look back at all pieces, see the picture and smile.
My deepest sense of gratitude goes to the ESTS team since we have grown together through rough and good times, with uncertainty as the only companion. Sometimes, I feel we are from the same neighbourhood. Dirk: thanks for sharing the vision and the burden. Semih, Richard, Michael, Laureano and Sue; rest assured that the best is yet to come.
At the end of my address, I cannot forget to pay a humble and heartfelt tribute to the two people who have supported my career all along and still amazingly bear with my peculiar view of the family life. In every way, I have saved the best for last.
Raffaele, you are by far my best achievement on this earth and I am so proud of being your father. Gina, thank you for Raffaele, the best birthday present you could possibly give me. Thank you for teaching me everyday a better way to be a human being while practicing as a surgeon, a father and a husband. With your love and support, I am still able to maintain my personal view from above. To you both: please remember that my quality rests in your eyes and in your hearts. In that safe place I call home.
To you all in the audience, even sophisticated words cannot express the honor and the privilege you have bestowed on me by asking to serve as your President. Therefore, I will use the simplest of sentences; wholeheartedly, thank you.
Footnotes
Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
