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Ann Thorac Surg 2000;69:321-325
© 2000 The Society of Thoracic Surgeons
a Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
Address reprint requests to Dr Baumgartner, Division of Cardiac Surgery, Johns Hopkins Hospital, 600 North Wolfe St, Blalock 618, Baltimore, MD 21287-4618
e-mail: wbaumgar{at}csurg.jhmi.jhu.edu
Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.
One of my proudest moments was hearing my name nominated as president-elect of the Southern Thoracic Surgical Association 2 years ago. It has been a real honor to serve you in this organization. This past year, I have had the pleasure of working with members of our Council, who have contributed significantly to the well-being of this organization. I would also like to thank the many other members who have given me guidance and support. I would especially like to thank my faculty and the residents who have supported me in all my endeavors. I am proud to have them as my colleagues and friends.
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My talk today is entitled, "Reassessing Our Core Values." What are core values? In 1997, the Dean and Chief Executive Officer of the Johns Hopkins School of Medicine, Dr Ed Miller, suggested that all department chairmen attend a 2 day retreat on the subject of core values. Under the gun from a myriad of external forces, he hoped to define and affirm what Hopkins was really about. He asked a former Stanford business professor, James Collins to be the facilitator.
Jim Collins and Jerry Porras had published a book entitled, "Built to Last: Successful Habits of Visionary Companies" [1]. In this book, they discuss the results of a 6 year research project carried out at Stanford’s business school. The study identified a number of so-called visionary companies who had a set of core values at the center of their organizations.
Visionary companies are premiere institutions, the crown jewels of their industries, which are widely admired by peers and have an excellent long track record of making a significant impact on the world around them.
He compared 18 visionary companies with 18 comparison companies (Table 1). All 36 companies are well-known, prosperous corporations. The comparison companies were not particularly bad companies, but by the authors’ definition they were not visionary. Many of them have outperformed the general stock market, but in the estimation of the authors they did not match their visionary counterparts. Visionary companies are more than successful, they are companies who may not have always prospered but have a tremendous resiliency, and were always able to bounce back from adversity (Fig 1). As a result, the visionary companies attained long-term performance that far exceeded comparison companies and the general market. For example, a dollar invested in the general stock market in 1926 would be worth $415.00 in the general stock market, and would be worth $955.00 in comparison companies, but worth $6,356 if that dollar had been invested in the visionary companies.
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Visionary companies were founded, and live by a series of core values. Core values are defined as "the organization’s essential and enduring tenets—a small set of general guiding principles; not to be confused with specific cultural or operating practices; not to be compromised for financial gain or short-term expediency" [1]. Core purpose is defined as "the organization’s fundamental reason for existence beyond just making money—a perpetual guiding star on the rise; and not to be confused with specific goals or business strategies" [1].
Two pharmaceutical companies, well-known to you, who illustrate the difference between visionary and nonvisionary companies are Merck and Pfizer. Merck developed a drug named Mectizan to cure river blindness, a parasitic disease that caused infections in over a million people annually in the Third World. A million customers may sound like a big market, but Merck knew that the project would not necessarily produce a large return on its investment. However, they moved forward with the hope that governmental agencies or a third party would purchase and distribute the drug. As it turned out, no one stepped forward. Merck elected to provide the drug free of charge and, in fact, distributed the drug at its own expense to be sure it reached the millions of people at risk of river blindness. As another example, Merck provided streptomycin to Japan after World War II to help eliminate tuberculosis. This produced no revenue for the company, but it is no accident that Merck is now the largest American pharmaceutical company in Japan. As Merck’s CEO pointed out, "The long-term consequences of such actions are not always clear, but somehow I think they always pay off."
Merck’s comparison company, Pfizer, has no story similar to Mectizan or streptomycin. During the same era, John McKean, president of Pfizer, displayed a somewhat lopsided perspective. He said, "So far as it is humanly possible, we aim to get profit out of everything we do."
Merck’s core values are summarized in Table 2. "We are in the business of preserving and improving human life. All of our actions must be measured by our success." The company’s core values include "honesty and integrity, corporate social responsibility, science-based innovation, not imitation, unequivocal excellence in all aspects of the company, profit but from work that benefits humanity" [1]. Core values provide an enduring focus that can span decades. Quotes, separated by 56 years, from two of Merck CEOs demonstrate this point. In 1935, George Merck II said, "We are workers in industry who are generally inspired by the ideals and advancement of medical science, and of service to humanity." Fifty-six years later in 1991, Chief Executive Officer P. Roy Vagelos said, "After all, let’s remember that our business success means victory against disease and help to human kind."
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Johnson & Johnson’s core values are the following: "The company exists ‘to alleviate pain and disease’ ... We have a hierarchy of responsibilities: customers first, employees second, society at large third, and shareholders fourth."
This Credo allowed Johnson & Johnson to respond to the 1982 Tylenol crisis in the Chicago area, when 7 people died from taking Tylenol that had been tampered with and laced with cyanide. Johnson & Johnson immediately recalled all Tylenol capsules from the entire United States market, at an estimated cost of 100 million dollars. Next they mounted a large public relations effort to alert and educate the public about the problem. A writer in the Washington Post commented, "Johnson & Johnson has succeeded in portraying itself to the public as a company willing to do what’s right, regardless of costs."
Note in comparison, that within days of the Tylenol crisis, Bristol-Myers faced a similar problem in the Denver market when Excedrin tablets had been potentially contaminated. Their reaction was different in that they recalled only those tablets from Colorado, and did not launch a campaign to alert the public. In an interview, the chairman of Bristol-Myers commented that the Excedrin incident would "have a negligible effect on Bristol-Myers’ earnings."
I think these two examples illustrate the benefit and power of having core values and adhering to them, whether it be a company, a group practice, a division, department, or university.
At the Johns Hopkins retreat, we broke into seven separate groups to discuss and determine what our individual core values were, since these would undoubtedly reflect those of Johns Hopkins Medicine. It is interesting to note that the core values listed here were nearly the same in each of the seven groups (Table 3).
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Although each of these core values is important within Johns Hopkins Medicine, I would like to draw your attention to the last one. This value is very important to me as the director of a thoracic surgery residency program. I think it is also a core value of the Southern Thoracic Surgical Association.
All of us are under pressure from outside payers and our own institutions to provide expedient service and timely operations, at a time when reimbursement is decreasing. These former goals are good, since they ultimately benefit our patients, but they may conflict with the training of residents.
As the decree to do more cases echoes throughout our divisions and practices, we are tempted to use our residents for more service obligations and restrict their operating room activity to first assisting. This clearly interferes with both their educational experience and growth.
I think the most important challenge to residency training is to maintain the appropriate balance between "clinical service, meaning direct involvement with patient care" and "education," which is exposing residents to thoracic surgical knowledge, the how and why of patient care.
In response to this challenge, we have all investigated new ways to provide surgical care and educate our residents. Many of these new protocols and techniques have been developed by members of this association.
One example of a small change in our own practice, was to create an operating room staffed only by faculty three times a week. This maintains the expedient flow of patients, and allows one resident to be outside the operating room during those times. We are fortunate to have a reasonable clinical volume that allows the residents to have an excellent operating room experience, while still providing some small break. We subscribe to the Shumway school of teaching surgery, in that we feel most cases can be performed by the resident with the attending surgeon as the assistant. Although patient care is always top priority, we remain committed to the training and education of our thoracic surgery residents. Core values of excellent patient care, resident education, and research are not mutually exclusive. Today’s medical world however makes it more difficult.
Some of the best and brightest people of our generation went into thoracic surgery, and many are members of this association. We have resourcefully responded to the pressure of managed care by radically changing our practices in and outside the operating room. This has resulted in lower costs, but also in improvement in patient care. We now need to raise the bar in our residency programs by considering their educational needs, and providing new, innovative educational resources and the time for our residents to use them.
As a member of the Thoracic Surgery Directors Association, I have been interested in applying new educational techniques to enhance resident education. I was dragged into the electronic era by my residents and colleagues and my two sons, but I now clearly understand and appreciate the power of the Internet as an educational tool to disseminate information in an exciting multimedia format.
Most surgical training programs today have their origin in the model created in 1891 by Dr William Halsted, the first Surgeon in Chief at the Johns Hopkins Hospital. The electronic approach to surgical education will not replace the traditional residency, which remains successful in the training of residents, in particular the practical management of the surgical patient. But the second component of the "making of a surgeon" is providing a theoretical framework for the knowledge base a surgeon will cultivate through his or her entire career. This has traditionally been carried out with lectures and slide presentations, occurring at times and places inconvenient to the resident. Teaching sessions are often interrupted by emergency cases and patient crises. There is a saying at Hopkins that if you are in need of a donor heart for an ill patient, just schedule a journal club. Finally, lectures are one time occurrences, which lead to difficulty in retention.
Longitudinal learning, then, is relegated to books, journals, atlases, and other methods to familiarize the resident about a particular topic of interest.
What if we could create an educational tool that was: (1) easy to use; (2) available at any time, day or night; (3) accessible from any location, including the operating room, outpatient clinic, patient floor, office, or importantly home; (4) capable of reviewing an entire subject or only a specific topic within that subject; (5) capable of in depth research on a particular subject with easy access to complete references, opinions from experts in the field, and expressed in a multimedia format; and finally (6) an enjoyable experience.
Today we have the technical ability to provide this type of innovative education. To demonstrate this, I would like to present excerpts from a project developed by one of my residents, Jorge Salazar, and myself. Another resident, John Doty, who is operating the computer for me today, has contributed to this project and been influential in my own education about this rapidly evolving field of electronic media.
There have been several developments in resident education based upon Internet technology, which clearly has helped to redefine the way medical education is presented. An important development in the field of cardiothoracic surgery is a web site on the Internet entitled, Cardiothoracic Surgery Network (www.CTSNet.org) (Fig 2). This site is a compilation of both national and international surgical organizations, and includes organizations involved in thoracic surgical residency training. The American Board of Thoracic Surgery and the Thoracic Surgery Directors Association (TSDA) are organizations listed on this web site. In addition, there is a Residents’ section (Fig 3) developed entirely by residents, which has a variety of helpful sections providing current information, a mechanism for recording operative cases, and education content for residents.
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The Southern Thoracic Surgical Association embraces and fosters many of the core values I have mentioned: integrity, respect for others, striving for excellence, and an emphasis on fostering leadership through education and teaching. Our association supports residents in many ways. It encourages resident participation in the scientific sessions. It has a Surgical Forum as a standing component of the annual program. Through Ron Elkins and Don Watson’s leadership, we have established the Hawley Seiler Resident Award, which is given each year to the resident with the most outstanding presentation and paper. We are the only organization that I am aware of that has a dedicated presentation in each year’s program on resident education. This idea was initiated by Gordon Murray during his Presidency, with the inaugural speaker being Ben Wilcox. This organization clearly has resident education as one of its core values. It is one of the many reasons I admire this association so much.
Those of us involved in residency training should reaffirm our commitment to this core value. Our residents are truly the future of our specialty and this association. By maintaining resident education and training as a core value, we will preserve our specialty and provide for the care of future patients with cardiothoracic disease. We should never waiver from this value, no matter what external forces are applied. Like the visionary company Johnson & Johnson, we should be willing to do what is right, regardless of costs. We need to develop new and innovative methods to more efficiently train and better educate our residents. The Internet provides the conduit for this new educational approach.
Educating and training the future leaders of our specialty is a core value shared by many people in this room. Through commitment to this value, and through the development of these innovative educational techniques, I am confident that our specialty and our patients will be in good hands for many years to come.
I would like to thank the members of this wonderful association for electing me president and for your kind attention.
References
This article has been cited by other articles:
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  J. P. Gold, W. B. Begg, D. A. Fullerton, D. J. Mathisen, M. B. Orringer, and E. D. Verrier Evaluation of Web-Based Learning Tools: Lessons Learned from the Thoracic Surgery Directors Association Curriculum Project Three-Year Experience Ann. Thorac. Surg., September 1, 2005; 80(3): 802 - 810. [Abstract] [Full Text] [PDF]
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J. P. Gold, E. A. Verrier, G. N. Olinger, and M. B. Orringer Development of a CD-ROM internet hybrid: a new thoracic surgery curriculum Ann. Thorac. Surg., November 1, 2002; 74(5): 1741 - 1746. [Full Text] [PDF]
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R. J. F. Baskett, K. J. Buth, J.-F. Legare, A. Hassan, C. H. Friesen, G. M. Hirsch, D. B. Ross, and J. A. Sullivan Is it safe to train residents to perform cardiac surgery? Ann. Thorac. Surg., October 1, 2002; 74(4): 1043 - 1049. [Abstract] [Full Text] [PDF]
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 W. A. Baumgartner and R. S. Stuart Building a clinical program in a single institution J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): S12 - 16. [Abstract] [Full Text] [PDF]
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