Memories of the Future

The 47 World Congress of Surgery: Basel August 13–17, 2017

The International Society of Surgery (ISS; also known as Societe’ Internationale de Chirugie) is the oldest international surgical society in the world. The first congress of the ISS was held in Brussels in 1905, and Dr. Emil Theodore Kocher was the first ISS president: 4 years later, he would be awarded the Nobel Prize for his work on the physiology, pathology, and surgery of the thyroid. The ISS has members in almost every country in the world, and today in Basel we have about 1800 participants from 93 countries (Fig. 1).

Fig. 1

ISS members around the world

Traditionally, the ISS has been led by prominent surgeons who have been at the helm of the Society for 24 months each. During the last three decades, however, the continuity of the mission of the society has been guaranteed by Mr. Victor Bertschi, who has been an effective and attentive Executive Director. Yesterday he became an Honorary Fellow of the International Society of Surgery in recognition of his work over 37 years. I also want to acknowledge our current office with Chris Storz and Mike Iliopoulos, and the local organizing committee led by Professor Pierre Clavien and Professor Nicholas Demartines. With the help of Professor Felix Harder (former ISS Secretary General), they were able to put together a great meeting in a short period of time in the beautiful city of Basel.

Finally, our thoughts go to two individuals who have recently passed, Professor Jean-Claude Givel and Professor Jay L. Grosfeld. Jean Claude Givel died in 2015 at the time of the opening ceremony of the World Congress of Surgery in Bangkok. He was the secretary general of the ISS, a gentleman and a scholar. Professor Grosfeld passed in 2016. He was the President of the World Federation of Association of Pediatric Surgeons and the Secretary of the ISS Foundation. He is a wonderful human being and a giant in the world of surgery. They will be greatly missed during this Congress.

Memories of the Future

As I started preparing my Presidential talk, I soon realized how taxing it was. To face an audience with thousands of surgeons from different countries and different cultures, brought together by the common passion for surgery, is not easy. I decided to avoid any particular surgical topic but rather to discuss my own journey, hoping that it could be inspirational. It was indeed quite a cathartic and emotional experience, as it gave me a chance to reflect on events of the past four decades, and people who have been part of my life.

One of these individuals was a patient I treated for gastric cancer when I was a junior attending surgeon at the University of California San Francisco (UCSF). Unfortunately, what I hoped to be a curative resection, turned out to be just an exploratory laparotomy as I found diffuse carcinomatosis, which had not been detected by the preoperative evaluation. Postoperatively, I remember sitting at the bedside, a young and inexperienced surgeon trying to find the best way to tell a patient that there was nothing else that could be done. I still remember his composure and his serenity listening to the news I was giving him and their fatality. And then, almost trying to console the young surgeon in front of him, he told me the story of his life. During the Second World War, he and his family had been deported to the Auschwitz concentration camp in Poland. He was the only one who survived and left the camp in 1945, while the rest of his family died in the gas chambers. He confided that what kept him alive during those horrible months was the dream of what he could have done, the life that he could have lived, had he survived. Years later, he wrote a book where he described how he had fulfilled during his life many of those dreams, how his Memories of the Future during those horrible years had eventually become a reality. His advice when he shook my hand was to live my life fully, to make it sure that my own dreams became a reality.

The memory of this encounter brought me to reflect on my own life, on my own Memories of the Future. To this individual I dedicate this talk.

I was born in Sicily, a small and peaceful island in the middle of the Mediterranean Sea. My father was a lawyer, my mother was a schoolteacher, and I was the youngest of four siblings. The focus of my teenage years was rowing. I did mostly single sculling, and while I never made it to the Olympic Games (which was my dream), I learned a lot from this experience. I learned the importance of working hard, I learned that it is not practice that makes you perfect but rather perfect practice, and I learned to blame only myself for my failures. After high school, at the age of 18 (in Italy there is no college), I enrolled into medical school, breaking a family tradition of law studies. At that time a famous driver for Ferrari died in a formula one race, and I still remember his words during an interview given a few days before………..“….to give a meaning to your life can lead you to folly, but a life without meaning is the torture of the unfulfilled desire, it is like a boat that wishes to be seaborne but is afraid of the sea….”. I realized that I wanted to do something that was meaningful not only for myself but also for others. While in medical school, I soon recognized that it was a full time job, and with great regret I abandoned rowing to fully dedicate myself to studying. During my senior year, I spent a couple of months at the Massachusetts General Hospital in Boston, on the general thoracic service lead by Dr. Hermes Grillo. I had met Dr. Grillo in Sicily during his visit in 1980 and I had learned that his father was originally from Noto, the same small town on the east coast of Sicily where my mother had lived. At the MGH I soon realized that I was on another planet, an incredible world where teaching and learning where the most important elements. Compared to American senior medical students, I felt inept: while I had an excellent fund of knowledge, I was missing the hand on experience typical of the senior year in American medical schools when students function as sub-intern. I felt that I could have never made it in the USA, and I decided to go back to Sicily and complete medical school. The memory of this experience remained alive in my mind, and eventually played a major role in subsequent years. Graduation from medical school was very exciting, both an ending and a beginning, warm memories of the past and big dreams for the future.

A couple of months later, I started a residency in General Surgery in Sicily. I imagined my career as very simple, like entering a well-lighted tunnel and following other people toward a clear end. However, my enthusiasm and expectations soon collided with the reality of training at the Vittorio Emanuele II hospital in Catania, Sicily. I soon realized that the transition made in the USA at Johns Hopkins in 1890 by Dr. Halsted, having the resident rather than the Professor at the center of the academic practice in a teaching Institution, had never occurred in Italy. Like planets that rotate around the sun, so nurses, residents, and junior attending surgeons rotated around the Professor, making it sure that He (there were no women in leadership positions in surgery in Italy) looked good. My personal experience consisted of first assisting in the operating room, having limited responsibility in patients’ care. After a couple of years of training, I realized that the reality was very different from what I had expected, and I summoned the courage to make an appointment to talk to the Chair of the Department. He had trained in the USA, in the same teaching environment I admired so much, so I felt confident that he would understand. The encounter, however, was simply surreal. While He acknowledged the value and effectiveness of the training in the USA, He clearly stated that he could not change the hierarchical system that had been in place in Sicily for centuries. However, he respected my desire for a better and different education, and he helped me to secure a scholarship for 1 year at UCSF, in the USA. On June 23, 1983, I showed up at the VA Hospital in San Francisco, and I met Dr. Lawrence Way and Dr Carlos Pellegrini, starting a journey that was supposed to last 12 months but that has now entered the 34th year.

For the following 3 years I worked under the supervision of Dr. Way and Dr. Pellegrini on an animal model to study biliary motility, and on patients tuning up a test that had been developed only a couple of years earlier—the radionuclide assessment of gastric emptying. I soon realized that it was a fantastic training environment, and started studying for the ECFMG and the FLEX, the required tests necessary to have my medical degree recognized. After the first year in the laboratory, I met Dr. Verna C. Gibbs who had just completed a residency in general surgery at UCSF, and we got married in 1985. I have a tremendous debt of gratitude as she provided a loving and supportive environment that allowed me to pass the tests, match at UCSF, and eventually go through a full residency in general surgery, spending more than 120 h every week in the hospital. The training at UCSF (at that time one of the top residency programs in surgery in the USA) was absolutely fantastic. We did clinical rotations in five hospitals, working with more than 100 surgeons, and learned from some of the best surgical minds such as Lawrence Way, Carlos Pellegrini, Orlo Clark, Ronald Stoney, and others.

I completed my residency at the end of June of 1993, and 1 week later I started a fellowship at the Queen Mary Hospital in Hong Kong, focusing on the treatment of patients with esophageal cancer under the guidance of Professor John Wong. It was not easy to leave my family—wife and a 4-year-old daughter—but it was indeed a unique and very valuable experience, from both a personal and professional point of view.

In 1994, I was hired by Dr. Haile Debas as an Assistant Professor of Surgery at UCSF, and I became the junior partner of Dr. Lawrence Way. I eventually spent an additional 14 years at UCSF, focusing mostly on minimally invasive foregut surgery, and progressed through the academic ranks. The last couple of years in San Francisco were very difficult. The department of surgery had slowly become mostly a transplant program with very little support for other divisions, and the morale of the faculty was very low. My wife and I also came to the realization that we had grown a part, and we decided to separate. In 2008 I moved to the University of Chicago with the goal of re-establishing a center for esophageal disorders, something that had disappeared after the departure of Dr. Tom DeMeester and Dr. David Skinner. It was very hard to move to Chicago and start from scratch in an environment very different from San Francisco. I was lucky as I had a supportive Chairman—Dr. Jeff Matthews—and I treasured the friendship with some of my colleagues, in particular Drs. Ed Kaplan, John Alverdy and Alessandro Fichera. The years I spent in Chicago were a time of personal and professional growth that I treasured, but at the same time I witnessed a dramatic change within the Institution. In part because of the changing world of medicine, in part because of poor leadership, the medical school slowly lost the interest in the academic mission and focused more and more on the business aspect of medicine. Scholarship and education became less and less important, and clinical productivity became the major goal. It was during this time of changes that I met a vascular surgeon from Northwestern University, Dr. Melina R. Kibbe. She was from the very beginning a breath of fresh air, a true believer in the academic mission, in the goal of mentoring residents and junior faculty, in contributing through research in addition to taking care of patients. She was able to resuscitate my enthusiasm for academic surgery, which had slowly gone away while at the University of Chicago. After a lovely engagement party in Seattle, in the home of Dr. Carlos Pellegrini, we got married in July 2013. When in 2016 she was offered the Chair of the Department of Surgery at the University of North Carolina in Chapel Hill, I was ready to move with her, as I believed that she was going to make a difference in that Institution (Fig. 2).

Fig. 2

Melina R. Kibbe, MD

This has been my long journey, and during the last 34 years, I have met many wonderful individuals. Among them, I would like to acknowledge some who have played a very important role. First and foremost my mentors—Carlos Pellegrini, John Wong, and Lawrence Way.

I met Carlos Alberto Pellegrini on June 23, 1983, in his office at the VA in San Francisco. What started that day was a lifelong friendship that has now lasted for 34 years. He was an inspiration for me as he was born in Argentina but after his training in Rosario, he had moved to the University of Chicago where he repeated his surgery residency, and then in 1979 he was hired as an Assistant Professor of Surgery at UCSF. I worked with him for 10 years, as a research fellow first and then as a resident, and I learned the importance of working hard and make dreams come true. Eventually he became Chairman at the University of Washington in Seattle, and President of many important surgical societies such as the American Surgical Association and the American College of Surgeons (Fig. 3).

Fig. 3

Carlos A. Pellegrini, MD

After I completed my residency, Dr. Haile Debas—Chairman of Surgery at UCSF—sent me to the Queen Mary Hospital in Hong Kong to learn about esophageal cancer surgery with Dr. John Wong. It was a full immersion in another world, and I enjoyed tremendously the cultural experience while learning a lot working with a master of surgery such as Professor Wong.

Upon my return to San Francisco, I became partners with Dr. Lawrence Way. Over the following 14 years, I learned day after day from the best surgeon I have ever met. As he always reminded me, what we do in the OR is just an operation, while surgery is the combination of preoperative evaluation, the operation, and postoperative care. He was a master in all of these components. He trained generations of surgeons, and even today when you ask a former UCSF resident who they remember as a key figure, his name comes up immediately. When I moved to Chicago or even today at UNC, I find myself telling the residents the same things Dr. Way used to tell me during the 24 years I spent with him. To date, I consider myself incredible lucky to have spent so many years working with him as a mentee, something that has shaped the rest of my career.

Many years have passed, and now that I am close to the end of the tunnel, which symbolizes the end of my career, I wonder if what I have done has been meaningful for me and for others, what will be my legacy, basically if I have realized my own Memories of the Future. While some surgeons feel that their legacy will be based on the manuscripts and books they published or on the leadership positions they held, I have a completely different view. As far as I am concerned, while I recognize that they are important, I hope that my own legacy will be based on something completely different. I believe that legacy is not what you do for yourself but rather what you do for others. I hope that some of the patients I treated will remember me for an operation well done, for the time spent at the bedside, or for holding their hand in difficult moments. I also believe that mentoring has been one of the most rewarding aspects of my career, a way to give back. I do hope that I have contributed, even minimally, to the career of some of the fellows I mentored over the years. Today some of them are in Basel as speakers at this congress and I hope they will soon make the transition themselves from mentees to mentors.

I would like to conclude with a message for the mentors and for the mentees.

To the mentors: we must acknowledge the characteristics of each generation, accepting them for what they are and treasuring the contribution that they can give. We need to accept them as a form of evolution, and not as a different and wrong way to be a surgeon.

To the mentee: it is a wonderful and fulfilling career. Keep the destination in view, but treasure every single moment of the journey.