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Schwartz’s
Principles of Surgery
Eleventh Edition
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Schwartz’s
Principles of Surgery
Eleventh Edition
Editor-in-Chief John G. Hunter, MD, FACS, FRCS Edin(Hon.)

F. Charles Brunicardi, MD, FACS Executive Vice President and CEO,
John Howard Endowed Professor of Pancreatic OHSU Health System
Surgery Mackenzie Professor of Surgery, School of Medicine
Chair, Department of Surgery Oregon Health and Science University
Director, Cancer Program Portland, Oregon
University of Toledo College of Medicine and Lillian S. Kao, MD, MS
Life Sciences Jack H. Mayfield, MD, Chair in Surgery
Academic Chief of Surgery Vice-Chair of Research and Faculty Development
ProMedica Health System Vice-Chair for Quality of Care
Toledo, Ohio Professor and Chief, Division of Acute Care Surgery
Department of Surgery
Associate Editors McGovern Medical School at the University of
Dana K. Andersen, MD, FACS Texas Health Science Center at Houston
Scientific Program Manager Houston, Texas
Division of Digestive Diseases and Nutrition Jeffrey B. Matthews, MD, FACS
National Institute of Diabetes and Digestive and Dallas B. Phemister Professor
Kidney Diseases Chair, Department of Surgery
National Institutes of Health Surgeon-in-Chief
Bethesda, Maryland The University of Chicago Pritzker School of
Timothy R. Billiar, MD, FACS Medicine
George Vance Foster Professor and Chair Chicago, Illinois
Department of Surgery Raphael E. Pollock, MD, PhD, FACS
University of Pittsburgh School of Medicine Director, The Ohio State University Comprehensive
Pittsburgh, Pennsylvania Cancer Center
David L. Dunn, MD, PhD Professor of Surgery; Kathleen Klotz Chair in
Prospect, Kentucky Cancer Research
The Ohio State University Wexner Medical Center
Columbus, Ohio
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Contents
Contributors/vii 13. Physiologic Monitoring of the

Surgical Patient..............................................433
Foreword/xxi
Anthony R. Cyr and Louis H. Alarcon
Foreword/xxiii 14. Minimally Invasive Surgery,
Preface/xxv Robotics, Natural Orifice Transluminal
Endoscopic Surgery, and Single-Incision
Volume 1 Laparoscopic Surgery ......................................453
Donn H. Spight, Blair A. Jobe, and John G. Hunter
Part I 15. Molecular Biology, The Atomic Theory
of Disease, and Precision Surgery.....................479
Basic Considerations 1 Xin-Hua Feng, Xia Lin, Xinran Li, Juehua Yu,
1. Leadership in Surgery ........................................ 3 John Nemunaitis, and F. Charles Brunicardi
Stephen Markowiak, Hollis Merrick, Shiela Beroukhim,
Jeremy J. Laukka, Amy Lightner, Munier Nazzal,
Lee Hammerling, James R. Macho, and F. Charles Brunicardi Part II
2. Systemic Response to Injury
Specific Considerations 511
and Metabolic Support ......................................27
Siobhan A. Corbett 16. The Skin and Subcutaneous Tissue ...................513
3. Fluid and Electrolyte Management of the Patrick Harbour and David H. Song
Surgical Patient................................................83 17. The Breast .....................................................541
Matthew D. Neal Catherine C. Parker, Senthil Damodaran,
4. Hemostasis, Surgical Bleeding, Kirby I. Bland, and Kelly K. Hunt
and Transfusion..............................................103 18. Disorders of the Head and Neck .......................613
Ronald Chang, John B. Holcomb, Evan Leibner, Antoine Eskander, Stephen Y. Kang,
Matthew Pommerening, and Rosemary A. Kozar Michael S. Harris, Bradley A. Otto, Oliver Adunka,
5. Shock ............................................................131 Randal S. Weber, and Theodoros N. Teknos
Brian S. Zuckerbraun, Andrew B. Peitzman, 19. Chest Wall, Lung, Mediastinum, and Pleura.......661
and Timothy R. Billiar Katie S. Nason, Rose B. Ganim, and James D. Luketich
6. Surgical Infections .........................................157 20. Congenital Heart Disease ................................751
Robert E. Bulander, David L. Dunn, and Raghav Murthy, Tabitha G. Moe, Glen A. Van Arsdell,
Greg J. Beilman John J. Nigro, and Tara Karamlou
7. Trauma ..........................................................183 21. Acquired Heart Disease ...................................801
Clay Cothren Burlew and Ernest E. Moore Matthew R. Schill, Ali J. Khiabani, Puja Kachroo,
8. Burns ............................................................251 and Ralph J. Damiano Jr
Jeffrey H. Anderson, Samuel P. Mandell, 22. Thoracic Aneurysms and Aortic Dissection ........853
and Nicole S. Gibran Scott A. LeMaire, Ourania Preventza, and Joseph S. Coselli
9. Wound Healing...............................................271 23. Arterial Disease .............................................897
Munier Nazzal, Mohammad F. Osman, Peter H. Lin, Carlos F. Bechara, Changyi Chen,
Heitham Albeshri, Darren B. Abbas, and Carol A. Angel and Frank J. Veith
10. Oncology .......................................................305 24. Venous and Lymphatic Disease ........................981
William E. Carson III, Funda Meric-Bernstam, and Atish Chopra, Timothy K. Liem,
Raphael E. Pollock and Gregory L. Moneta
11. Transplantation ..............................................355 25. Esophagus and Diaphragmatic Hernia .............1009
David L. Dunn, Angelika C. Gruessner, and Blair A. Jobe, John G. Hunter, and David I. Watson
Rainer W.G. Gruessner 26. Stomach ......................................................1099
12. Quality, Patient Safety, Assessments Robert E. Roses and Daniel T. Dempsey
of Care, and Complications ..............................397
Martin A. Makary, Peter B. Angood, and
Mark L. Shapiro
vi
Volume 2 42. Neurosurgery ...............................................1827
Ashwin G. Ramayya, Saurabh Sinha,
27. The Surgical Management of Obesity ..............1167 and M. Sean Grady
Anita P. Courcoulas and Philip R. Schauer 43. Orthopedic Surgery .......................................1879
28. Small Intestine ............................................1219 Nabil A. Ebraheim, Bert J. Thomas, Freddie H. Fu,
Ali Tavakkoli, Stanley W. Ashley, and Bart Muller, Dharmesh Vyas, Matt Niesen,
Michael J. Zinner Jonathan Pribaz, and Klaus Draenert
44. Surgery of the Hand and Wrist .......................1925
Contents
29. Colon, Rectum, and Anus ..............................1259

Mary R. Kwaan, David B. Stewart Sr, and Scott D. Lifchez and Brian H. Cho
Kelli Bullard Dunn 45. Plastic and Reconstructive Surgery.................1967
30. The Appendix ...............................................1331 Rajiv Y. Chandawarkar, Michael J. Miller,
Fadi S. Dahdaleh, David Heidt, and Kiran K. Turaga Brian C. Kellogg, Steven A. Schulz, Ian L. Valerio,
31. Liver ...........................................................1345 and Richard E. Kirschner
David A. Geller, John A. Goss, Ronald W. Busuttil, and 46. Anesthesia for Surgical Patients ....................2027
Allan Tsung Junaid Nizamuddin and Michael O’Connor
32. Gallbladder and the Extrahepatic 47. Surgical Considerations in
Biliary System..............................................1393 Older Adults.................................................2045
Kelly R. Haisley and John G. Hunter Anne M. Suskind and Emily Finlayson
33. Pancreas ......................................................1429 48. Ethics, Palliative Care, and Care
William E. Fisher, Dana K. Andersen, at the End of Life .........................................2061
John A. Windsor, Vikas Dudeja, Daniel E. Hall, Eliza W. Beal, Peter A. Angelos,
and F. Charles Brunicardi Geoffrey P. Dunn, Daniel B. Hinshaw,
34. The Spleen...................................................1517 and Timothy M. Pawlik
Adrian E. Park, Eduardo M. Targarona, 49. Global Surgery..............................................2077
Adam S. Weltz, and Carlos Rodriguez-Otero Luppi Katherine E. Smiley, Haile T. Debas,
35. Abdominal Wall, Omentum, Mesentery, and Catherine R. deVries, and Raymond R. Price
Retroperitoneum ..........................................1549 50. Optimizing Perioperative Care: Enhanced
Scott Kizy and Sayeed Ikramuddin Recovery and Chinese Medicine .....................2113
36. Soft Tissue Sarcomas ....................................1567 Jennifer Holder-Murray, Stephen A. Esper,
Ricardo J. Gonzalez, Alessandro Gronchi, Zhiliang Wang, Zhigang Cui, and Xima Wang
and Raphael E. Pollock 51. Understanding, Evaluating, and Using
37. Inguinal Hernias ..........................................1599 Evidence for Surgical Practice .........................2137
Chandan Das, Tahir Jamil, Stephen Stanek, Andrew J. Benjamin, Andrew B. Schneider,
Ziya Baghmanli, James R. Macho, Joseph Sferra, Jeffrey B. Matthews, and Gary An
and F. Charles Brunicardi 52. Ambulatory Surgery ......................................2153
38. Thyroid, Parathyroid, and Adrenal ..................1625 Marcus Adair, Stephen Markowiak, Hollis Merrick,
Geeta Lal and Orlo H. Clark James R. Macho, Kara Richardson, Moriah Muscaro,
39. Pediatric Surgery ..........................................1705 Munier Nazzal, and F. Charles Brunicardi
David J. Hackam, Jeffrey Upperman, 53. Skills and Simulation....................................2163
Tracy Grikscheit, Kasper Wang, and Henri R. Ford Neal E. Seymour and Carla M. Pugh
40. Urology .......................................................1759 54. Web-Based Education and Implications
Ahmad Shabsigh, Michael Sourial, Fara F. Bellows, of Social Media ............................................2187
Christopher McClung, Rama Jayanthi, Stephanie Kielb, Lillian S. Kao and Michael E. Zenilman
Geoffrey N. Box, Bodo E. Knudsen, and Cheryl T. Lee
Index/2197
41. Gynecology ..................................................1783
Sarah M. Temkin, Thomas Gregory,
Elise C. Kohn, and Linda Duska
Contributors
Darren B. Abbas, MD Dana K. Andersen, MD, FACS

Clinical Instructor Scientific Program Manager
Department of Surgery Division of Digestive Diseases and Nutrition
University of Toledo College of Medicine and National Institute of Diabetes and Digestive and
Life Sciences Kidney Diseases
Toledo, Ohio National Institutes of Health
Chapter 9, Wound Healing Bethesda, Maryland
Chapter 33, Pancreas
Marcus Adair, MD
Clinical Instructor Jeffrey H. Anderson, MD
Department of Surgery Resident, Department of Surgery
University of Toledo College of Medicine and Harborview Medical Center
Life Sciences Seattle, Washington
Toledo, Ohio Chapter 8, Burns
Chapter 52, Ambulatory Surgery
Carol A. Angel, MD
Oliver Adunka, MD, FACS Clinical Instructor
Professor Department of Surgery
Vice-Chair, Clinical Operations University of Toledo College of Medicine and
Department of Otolaryngology-Head and Neck Surgery Life Sciences
Director, Division of Otology/Neurotology and Cranial Toledo, Ohio
Base Surgery Chapter 9, Wound Healing
The Ohio State University-James Comprehensive
Peter A. Angelos, MD, PhD, FACS
Cancer Center
Linda Kohler Anderson Professor of Surgery and
Columbus, Ohio
Surgical Ethics
Chapter 18, Disorders of the Head and Neck
Chief, Endocrine Surgery
Louis H. Alarcon, MD, FACS, FCCM Associate Director
Professor of Surgery and Critical Care Medicine MacLean Center for Clinical Medical Ethics
Medical Director, Division of Trauma Surgery The University of Chicago Medicine
University of Pittsburgh Chicago, Illinois
Pittsburgh, Pennsylvania Chapter 48, Ethics, Palliative Care, and Care at the
Chapter 13, Physiologic Monitoring of the Surgical Patient End of Life
Heitham Albeshri, MD Peter B. Angood, MD, CPE, FRCS(C), FACS, MCCM
Clinical Instructor President and Chief Executive Officer
Department of Surgery American Association for Physician Leadership
University of Toledo College of Medicine and Life Sciences Tampa, Florida
Toledo, Ohio Chapter 12, Quality, Patient Safety, Assessments of Care,
Chapter 9, Wound Healing and Complications
Gary An, MD Glen S. Van Arsdell, MD
Professor of Surgery Chief, Pediatric Cardiac Surgery
Department of Surgery Mattel Children’s Hospital
The University of Chicago Medicine University of California
Chicago, Illinois Los Angeles, California
Chapter 51, Understanding, Evaluating, and Using Chapter 20, Congenital Heart Disease
Evidence for Surgical Practice
viii Stanley W. Ashley, MD Kirby I. Bland, MD
General & Gastrointestinal Surgery Fay Fletcher Kerner Professor
Brigham and Women’s Hospital The University of Alabama at Birmingham
Frank Sawyer Professor of Surgery Department of Surgery
Harvard Medical School Birmingham, Alabama
Boston, Massachusetts Chapter 17, The Breast
Contributors
Chapter 28, Small Intestine

Geoffrey N. Box, MD
Ziya Baghmanli, MD Assistant Professor
Clinical Instructor Department of Urology
Department of Surgery The Ohio State University
University of Toledo Medical Center Columbus, Ohio
Toledo, Ohio Chapter 40, Urology
Chapter 37, Inguinal Hernias
F. Charles Brunicardi, MD, FACS
Eliza W. Beal John Howard Endowed Professor of Pancreatic Surgery
Clinical Instructor, Department of General Surgery Chair, Department of Surgery
The Ohio State University Director, Cancer Program
Columbus, Ohio University of Toledo College of Medicine and
Chapter 48, Ethics, Palliative Care, and Care at the Life Sciences
End of Life Academic Chief of Surgery
ProMedica Health System
Carlos F. Bechara, MD
Toledo, Ohio
Associate Professor of Surgery
Chapter 1, Leadership in Surgery
Program Director, Vascular Surgery Fellowship
Chapter 15, Molecular Biology, The Atomic Theory of
Disease, and Precision Surgery
Loyola University Medical Center
Maywood, Illinois
Chapter 23, Arterial Disease
Greg J. Beilman, MD
Robert E. Bulander, Jr., MD, PhD
Owen H and Sarah Davidson Wangensteen Chair of
Assistant Professor of Surgery
Experimental Surgery
University of Minnesota
Minneapolis, Minnesota
Chapter 6, Surgical Infections
Clay Cothren Burlew, MD, FACS
Fara F. Bellows, MD
Professor of Surgery
Clinical Assistant Professor
Director, Surgical Intensive Care Unit
Department of Urology
Program Director, Surgical Critical Care Fellowship
The Ohio State University
Program Director, Trauma & Acute Care Surgery
Columbus, Ohio
Fellowship
Chapter 40, Urology
The Ernest E. Moore Shock Trauma Center
Andrew J. Benjamin, MD, MS Denver Health Medical Center
The University of Chicago Medicine University of Colorado School of Medicine
Chicago, Illinois Denver, Colorado
Chapter 51, Understanding, Evaluating, and Chapter 7, Trauma
Using Evidence for Surgical Practice
Ronald W. Busuttil, MD, PhD
Shiela Beroukhim, MD William P. Longmire, Jr., Chair in Surgery
Clinical Instructor Professor and Executive Chair
Harbor-UCLA Medical Center Department of Surgery
Torrance, California David Geffen School of Medicine at University of
Chapter 1, Leadership in Surgery California-Los Angeles
Los Angeles, California
Timothy R. Billiar, MD, FACS
Chapter 31, Liver
George Vance Foster Professor and Chair
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Chapter 5, Shock
William E. Carson III, MD, FACS Joseph S. Coselli, MD ix
Professor of Surgery and Vice Chair for Promotion Vice-Chair, Michael E. DeBakey Department of Surgery
and Tenure Professor, Cullen Foundation Endowed Chair
The John B. and Jane T. McCoy Chair in Cancer Chief, Division of Cardiothoracic Surgery
Research Baylor College of Medicine
Interim Chief, Division of Surgical Oncology Chief, Adult Cardiac Surgery Texas Heart Institute
Contributors
Associate Director for Clinical Research Chief, Adult Cardiac Surgery Section
OSU Comprehensive Cancer Center Associate Chief, Cardiovascular Service
The Ohio State University Baylor St. Luke’s Medical Center
Columbus, Ohio Houston, Texas
Chapter 10, Oncology Chapter 22, Thoracic Aneurysms and Aortic Dissection
Rajiv Y. Chandawarkar, MD, MBA Anita P. Courcoulas, MD, MPH, FACS
Acting Chair Professor of Surgery
Department of Plastic and Reconstructive Surgery Section Head, MIS Bariatric & General Surgery
The Ohio State University Wexner Medical Center University of Pittsburgh Medical Center
Columbus Ohio Pittsburgh, Pennsylvania
Chapter 45, Plastic and Reconstructive Surgery Chapter 27, The Surgical Management of Obesity
Ronald Chang, MD Zhigang Cui, MD
Department of Surgery Associate Professor of Surgery
University of Texas Houston Department of Surgery
Houston, Texas Tianjin Medical University
Chapter 4, Hemostasis, Surgical Bleeding, and Nankai Hospital
Transfusion Institute of Acute Abdomen of Tianjin,
Tianjin, China
Changyi Chen, MD, PhD
Chapter 50, Optimizing Perioperative Care: Enhanced
Recovery and Chinese Medicine
Michael E. DeBakey Department of Surgery
Baylor College of Medicine Anthony R. Cyr, MD, PhD
Houston, Texas Clinical Instructor
Chapter 23, Arterial Disease Department of Surgery
Brian H. Cho, MD
Resident in Plastic Surgery
Chapter 13, Physiologic Monitoring of the Surgical Patient
Johns Hopkins Department of Plastic Surgery
Baltimore, Maryland Fadi S. Dahdaleh, MD
Chapter 44, Surgery of the Hand and Wrist Department of Surgery
University of Chicago
Atish Chopra, MD
Chicago, Illinois
Fellow, Division of Vascular Surgery
Chapter 30, The Appendix
Oregon Health & Science University Ralph J. Damiano, MD
Portland, Oregon Evarts A. Graham Professor of Surgery
Chapter 24, Venous and Lymphatic Disease Chief, Division of Cardiothoracic Surgery
Co-Chair, Heart & Vascular Center
Orlo H. Clark, MD, FACS
Washington University School of Medicine
Professor Emeritus, Department of Surgery
St Louis, Missouri
UCSF Mt Zion Medical Center
Chapter 21, Acquired Heart Disease
San Francisco, California
Chapter 38, Thyroid, Parathyroid, and Adrenal Senthil Damodaran, MD, PhD
Assistant Professor
Siobhan A. Corbett, MD
Departments of Breast Medical Oncology and
Investigational Cancer Therapeutics
The University of Texas MD Anderson Cancer Center
Rutgers-Robert Wood Johnson Medical School
Houston, Texas
Rutgers Biomedical and Health Sciences
Chapter 17, The Breast
New Brunswick, New Jersey
Chapter 2, Systemic Response to Injury and
Metabolic Support
x Chandan Das, MD Kelli Bullard Dunn, MD, FACS, FASCRS
Clinical Instructor Vice Dean, Community Engagement and Diversity
Department of Surgery Professor of Surgery
University of Toledo College of Medicine and Life Sciences University of Louisville School of Medicine
Toledo, Ohio Louisville, Kentucky
Chapter 37, Inguinal Hernias Chapter 29, Colon, Rectum, and Anus
Contributors
Haile T. Debas, MD, FACS Nabil A. Ebraheim, MD

Maurice Galante Distinguished Professor of Surgery, Chairman and Professor
Emeritus Department of Orthopaedic Surgery
Founding Executive Director, Global Health Sciences The University of Toledo Medical Center
Director Emeritus, University of California Global Toledo, Ohio
Health Institute Chapter 43, Orthopedic Surgery
Dean Emeritus, School of Medicine
Antoine Eskander, MD, ScM, FRCSC
Former Chancellor
Assistant Professor, University of Toronto
University of California, San Francisco
Department of Otolaryngology—Head & Neck Surgery
Sunnybrook Health Sciences Centre, Surgical Oncologist
Chapter 49, Global Surgery
Michael Garron Hospital, Endocrine Surgery
Daniel T. Dempsey, MD, FACS Institute for Clinical Evaluative Sciences (ICES),
Professor of Surgery Adjunct Scientist
Department of Surgery Toronto, Ontario, Canada
Perelman School of Medicine Chapter 18, Disorders of the Head and Neck
University of Pennsylvania
Stephen A. Esper, MD, MBA
Philadelphia, Pennsylvania
Assistant Professor
Chapter 26, Stomach
Department of Anesthesiology and Perioperative
Catherine R. deVries, MD Medicine
Professor of Surgery Director, UPMC Centers for Perioperative Care
Adjunct Associate Professor of Family Medicine/ University of Pittsburgh Medical Center
Public Health Pittsburgh, Pennsylvania
University of Utah Chapter 50, Optimizing Perioperative Care: Enhanced
Salt Lake City, Utah Recovery and Chinese Medicine
Xin-Hua Feng, PhD
Vikas Dudeja, MD Distinguished Investigator
Assistant Professor of Surgery Life Sciences Institute
Division of Surgical Oncology Zhejiang University
Department of Surgery Hangzhou, Zhejiang, China
University of Miami Professor of Molecular Cell Biology
Miami, Florida Michael E. DeBakey Department of Surgery and
Chapter 33, Pancreas Department of Molecular & Cellular Biology
Baylor College of Medicine
David L. Dunn, MD, PhD
Houston, Texas
Prospect, Kentucky
Chapter 11, Transplantation
Emily Finlayson, MD, MS, FACS
Geoffrey P. Dunn, MD
Professor in Residence
Medical Director
Department of Surgery, Division of General Surgery
Department of Medicine, Division of Geriatrics
Hamot Medical Center
Phillip R. Lee Institute for Health Policy Studies
Erie, Pennsylvania
Director, Center for Surgery in Older Adults
Chapter 48, Ethics, Palliative Care, and Care at the
Director, Department of Surgery Faculty Mentoring
End of Life
Program
University of California San Francisco
Chapter 47, Surgical Considerations in Older Adults
William E. Fisher, MD, FACS M. Sean Grady, MD xi
Professor of Surgery, Clinical Vice Chair and Charles Harrison Frazier Professor
Chief, Division of General Surgery Chairman
George L. Jordan, MD Chair of General Surgery Department of Neurosurgery
Michael E. DeBakey Department of Surgery Perelman School of Medicine at University of
Director, Elkins Pancreas Center Pennsylvania
Contributors
Baylor College of Medicine Philadelphia, Pennsylvania
Houston, Texas Chapter 42, Neurosurgery
Angelika Gruessner, PhD
Henri R. Ford, MD, MHA Professor of Medicine
Dean and Chief Academic Officer State University of New York (SUNY-Downstate)
University of Miami Miller School of Medicine New York, New York
Don Soffer Clinical Research Center Chapter 11, Transplantation
Miami, Florida
Rainer Gruessner, MD
Chapter 39 Pediatric Surgery
Clarence & Mary Dennis Professor of Surgery
Freddie H. Fu, MD, DSc (Hon.), DPs (Hon.) Chairman, Department of Surgery
Distinguished Service Professor State University of New York (SUNY-Downstate)
University of Pittsburgh New York, New York
David Silver Professor and Chairman Chapter 11, Transplantation
Department of Orthopaedic Surgery
David J. Hackam, MD, PhD, FACS
Garrett Professor and Chief of Pediatric Surgery
Head Team Physician
Professor of Surgery, Pediatrics and Cell Biology
University of Pittsburgh Department of Athletics
Johns Hopkins University School of Medicine
Pediatric Surgeon-in-Chief and Co-Director
Chapter 43, Orthopedic Surgery
Johns Hopkins Children’s Center
David A. Geller, MD The Charlotte R. Bloomberg Children’s Center
Richard L. Simmons Professor of Surgery Baltimore, Maryland
Chief, Division of Hepatobiliary and Pancreatic Surgery Chapter 39, Pediatric Surgery
Kelly R. Haisley, MD
Clinical Instructor
Chapter 31, Liver
Nicole S. Gibran, MD, FACS Oregon Health and Science University
Professor, Department of Surgery Portland, Oregon
Associate Dean, Research and Graduate Education Chapter 32, Gallbladder and the Extrahepatic Biliary
Harborview Medical Center System
University of Washington School of Medicine
Lee Hammerling, MD
Seattle, Washington
Chief Academic Officer
Chapter 8, Burns
President, New Ventures
Ricardo J. Gonzalez, MD, FACS ProMedica Health System
Chair, Sarcoma Department Toledo, Ohio
Professor of Surgery Chapter 1, Leadership in Surgery
Chief of Surgery, Moffitt Cancer Center
Patrick Harbour, MD
Tampa, Florida
Department of Plastic Surgery
Chapter 36, Soft Tissue Sarcoma
MedStar Georgetown University Hospital
John A. Goss, MD Washington, DC
Professor of Surgery Chapter 16, The Skin and Subcutaneous Tissue
Michael S. Harris, MD
Division of Abdominal Transplantation and
Assistant Professor, Department of Otolaryngology
Hepatobiliary Surgery
Assistant Professor, Medical College of Wisconsin
Department of Otolaryngology & Communication
Houston, Texas
Sciences
Chapter 31, Liver
Division of Neurotology & Skull Base Surgery
Milwaukee, Wisconsin
xii David G. Heidt, MD, FACS Tahir Jamil, MD
Clinical Associate Professor Clinical Assistant Professor of Surgery
University of Toledo College of Medicine University of Toledo College of Medicine and
Staff Surgeon, St. Joseph Mercy Medical Center Life Sciences
Ann Arbor, Michigan Department of Surgery
Chapter 30, The Appendix Promedica Health System
Contributors
Toledo, Ohio
Daniel B. Hinshaw, MD
Professor
Department of Surgery Rama Jayanthi, MD
University of Michigan Chief, Pediatric Urology
Ann Arbor, Michigan Nationwide Children’s Hospital
Chapter 48, Ethics, Palliative Care, and Care at the Dayton Children’s Hospital
End of Life Clinical Professor, Department of Urology
John B. Holcomb, MD
Columbus, Ohio
Chapter 40, Urology
University of Texas Houston Blair A. Jobe, MD, FACS
Houston, Texas Chair of Surgery, Western Pennsylvania Hospital
Chapter 4, Hemostasis, Surgical Bleeding, and Director, Institute for the Treatment of Esophageal
Transfusion and Thoracic Disease, Allegheny Health Network
Jennifer Holder-Murray, MD, FACS, FASCRS
Chapter 14, Minimally Invasive Surgery, Robotics,
Vice Chair of Quality Integration
Natural Orifice Transluminal Endoscopic Surgery, and
Assistant Professor Surgery
Single-Incision Laparoscopic Surgery
Division of Colon and Rectal Surgery
Chapter 25, Esophagus and Diaphragmatic Hernia
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Puja Kachroo, MD
Chapter 50, Optimizing Perioperative Care: Enhanced Clinical Instructor
Recovery and Chinese Medicine Division of Cardiothoracic Surgery, Department of
Surgery
Kelly K. Hunt, MD, FACS
Washington University School of Medicine
Hamill Foundation
Barnes-Jewish Hospital
Distinguished Professor of Surgery in
St. Louis, Missouri
Honor of Dr. Richard G. Martin Sr.
Chapter 21, Acquired Heart Disease
Chair, Department of Breast Surgical Oncology
The University of Texas MD Anderson Cancer Center Stephen Y. Kang, MD
Houston, Texas Assistant Professor
Chapter 17, The Breast Department of Otolaryngology—Head and Neck Surgery
Division of Head and Neck Oncology
John G. Hunter, MD, FACS, FRCS Edin(Hon.)
The Ohio State University—James Comprehensive
Executive Vice President and CEO, OHSU Health System
Cancer Center
Mackenzie Professor of Surgery, School of Medicine
Columbus, Ohio
Oregon Health and Science University
Portland, Oregon
Chapter 14, Minimally Invasive Surgery, Robotics, Lillian S. Kao, MD, MS
Natural Orifice Transluminal Endoscopic Surgery, and Jack H. Mayfield, MD, Chair in Surgery
Single-Incision Laparoscopic Surgery Vice-Chair of Research and Faculty Development
Chapter 25, Esophagus and Diaphragmatic Hernia Vice-Chair for Quality of Care
Chapter 32, Gallbladder and the Extrahepatic Biliary Department of Surgery
System McGovern Medical School at the University of Texas
Health Science Center at Houston
Sayeed Ikramuddin, MD, MHA
Houston, Texas
Jay Phillips Professor and Chair
Chapter 54, Web-Based Education and Implications of
Social Media
University of Minnesota Medical School
Chapter 35, Abdominal Wall, Omentum, Mesentery, and
Retroperitoneum
Tara Karamlou, MD, MSc Rosemary A. Kozar, MD, PhD xiii
Professor of Surgery, Division of Pediatric Professor of Surgery
Cardiac Surgery Director of Translational Research at Shock Trauma
Cleveland Clinic Associate Director of Shock Trauma Anesthesia
Cleveland, Ohio Research (STAR) Center
Chapter 20, Congenital Heart Disease University of Maryland School of Medicine
Contributors
Baltimore, Maryland
Brian C. Kellogg, MD
Chapter 4, Hemostasis, Surgical Bleeding, and
Plastic and Reconstructive Surgery
Transfusion
Nationwide Children’s Hospital
700 Children’s Dr Mary R. Kwaan, MD, MPH
Columbus, Ohio Associate Professor of Surgery
University of California, Los Angeles
Ali J. Khiabani, MD, MHA
Resident Physician
Chapter 29, Colon, Rectum, and Anus
Washington University School of Medicine Geeta Lal, MD, MSc, FRCS(C), FACS
St. Louis, Missouri Associate Professor, Surgery
Chapter 21, Acquired Heart Disease Associate Chief Quality Officer, Inpatient
University of Iowa
Stephanie Kielb, MD
Iowa City, Iowa
Associate Professor
Chapter 38, Thyroid, Parathyroid, and Adrenal
Departments of Urology, Medical Education, and
Obstetrics and Gynecology Jeremy J. Laukka
Northwestern University Feinberg School of Medicine Associate Professor of Medical Education & Neurology
Chicago, Illinois Department of Medical Education
Chapter 40, Urology Associate Dean for Foundational Science Curriculum
University of Toledo College of Medicine and
Richard E. Kirschner, MD
Life Sciences
Chief, Plastic and Reconstructive Surgery
Toledo, Ohio
Nationwide Children’s Hospital
Columbus, Ohio
Chapter 45, Plastic and Reconstructive Surgery Cheryl T. Lee, MD
Dorothy M. Davis Endowed Chair in Cancer Research
Scott Kizy, MD
Professor and Chairman
Resident in Surgery
Columbus, Ohio
Chapter 35, Abdominal Wall, Omentum, Mesentery, and
Chapter 40, Urology
Retroperitoneum
Evan Leibner, MD, PhD
Bodo E. Knudsen, MD, FRCSC
Assistant Professor
Henry A. Wise II Endowed Chair in Urology
Institute of Critical Care Medicine & Department of
Associate Professor
Emergency Medicine
Mount Sinai Medical Center
Icahn School of Medicine at Mount Sinai
Columbus, Ohio
New York, New York
Chapter 40, Urology
Chapter 4, Hemostasis, Surgical Bleeding, and Transfusion
Elise C. Kohn, MD
Head, Gynecologic Cancer and Neuroendocrine Cancer
Therapeutics
Clinical Investigations Branch
Cancer Therapy Evaluation Program
National Cancer Institute
Bethesda, Maryland
Chapter 41, Gynecology
xiv Scott A. LeMaire, MD Xia Lin, PhD
Jimmy and Roberta Howell Professor of Cardiovascular Associate Professor of Surgery
Surgery Michael E. DeBakey Department of Surgery
Vice Chair for Research, Michael E. DeBakey Baylor College of Medicine
Department of Surgery Houston, Texas
Professor of Molecular Physiology and Biophysics Chapter 15, Molecular Biology, The Atomic Theory of
Contributors
Director of Research, Division of Cardiothoracic Disease, and Precision Surgery

Surgery
James D. Luketich, MD
Henry T. Bahnson Professor of Cardiothoracic
Department of Cardiovascular Surgery, Texas Heart
Surgery, Chief, The Heart, Lung, and Esophageal
Institute
Surgery Institute, Department of Surgery
Baylor St. Luke’s Medical Center
Division of Thoracic and Foregut Surgery
Houston, Texas
University of Pittsburgh
Chapter 22, Thoracic Aneurysms and Aortic Dissection
Xinran Li, PhD Chapter 19, Chest Wall, Lung, Mediastinum, and Pleura
Postdoctoral Fellow
Carlos Rodriguez-Otero Luppi, MD, PhD
Life Sciences Institute
Unit of Gastrointestinal and Hematological
Zhejiang University
Surgery, Hospital Sant Pau
Hangzhou, Zhejiang, China
Professor of Surgery,
Autonomous University of Barcelona
Barcelona, Spain
Timothy K. Liem, MD, FACS Chapter 34, The Spleen
Professor of Surgery, Vice-Chair for Quality
James R. Macho, MD, FACS
Department of Surgery, Knight Cardiovascular Institute
Emeritus Professor of Surgery
Oregon Health & Science University
University of California, San Francisco
Portland, Oregon
Chapter 24, Venous and Lymphatic Disease
Scott D. Lifchez, MD, FACS Chapter 37, Inguinal Hernias
Associate Professor of Plastic Surgery and Chapter 52, Ambulatory Surgery
Orthopedic Surgery
Martin A. Makary, MD, MPH, FACS
Program Director, Johns Hopkins/University of
Maryland Plastic Surgery Residency
Johns Hopkins University
Director of Hand Surgery
Baltimore, Maryland
Johns Hopkins Bayview Medical Center
Chapter 12, Quality, Patient Safety, Assessments of Care,
Baltimore, Maryland
and Complications
Chapter 44, Surgery of the Hand and Wrist
Samuel P. Mandell, MD, MPH, FACS
Amy Lightner, MD Assistant Professor
Mayo Clinic College of Medicine
University of Washington School of Medicine
Medical Director of Translation Into Practice Platforms
UW Medicine Regional Burn Center
Center for Regenerative Medicine, Mayo Clinic
Harborview Medical Center
Senior Associate Consultant, Department of Surgery
Seattle, Washington
Mayo Clinic College of Medicine
Chapter 8, Burns
Division of Colon and Rectal Surgery
Rochester, Minnesota Stephen Markowiak, MD
Chapter 1, Leadership in Surgery Clinical Instructor
Peter H. Lin, MD University of Toledo College of Medicine and
Professor Emeritus of Surgery
Life Sciences
Toledo, Ohio
Houston, Texas
Chapter 23, Arterial Disease
Jeffrey B. Matthews, MD, FACS Ernest E. Moore, MD xv
Dallas B. Phemister Professor Ernest E. Moore Shock Trauma Center at Denver Health
Chair, Department of Surgery Distinguished Professor of Surgery, University of
Surgeon-in-Chief Colorado Denver
The University of Chicago Pritzker School of Medicine Editor, Journal of Trauma
Chicago, Illinois Denver, Colorado
Contributors
Chapter 51, Understanding, Evaluating, and Using Chapter 7, Trauma
Evidence for Surgical Practice
Bart Muller, MD, PhD
Christopher McClung, MD Orthopaedic Surgeon
Adjunct Professor Academic Medical Center
The Ohio State University Amsterdam, The Netherlands
Reconstructive Urologist Chapter 43, Orthopedic Surgery
The Central Ohio Urology Group
Raghav Murthy, MD, DABS, FACS
Columbus, Ohio
Assistant Professor
Chapter 40, Urology
Director, Pediatric Heart Transplantation
Funda Meric-Bernstam, MD Division of Pediatric Cardiac Surgery
Chair, Department of Investigational Cancer Kravis Children’s at Mount Sinai Hospital
Therapeutics; Medical Director, Institute for Icahn School of Medicine,
Personalized Cancer Therapy; Professor, Divisions New York, New York
of Cancer Medicine and Surgery Chapter 20, Congenital Heart Disease
MD Anderson Cancer Center
Moriah Muscaro, MD
Houston, Texas
Clinical Instructor
Chapter 10, Oncology
Hollis Merrick, MD, FACS Life Sciences
Professor Emeritus Toledo, Ohio
Department of Surgery Chapter 52, Ambulatory Surgery
Katie S. Nason, MD, MPH
Life Sciences
Vice-Chair for Surgical Research, Department of
Toledo, Ohio
Surgery
Fellow, Institute for Healthcare Delivery and Population
Michael J. Miller, MD, FACS Science
Professor and Chair Thoracic Surgeon, Division of Thoracic Surgery
Department of Plastic and Reconstructive Surgery University of Massachusetts Medical School—Baystate
The Ohio State University Health
Wexner Medical Center Springfield, Massachusetts
Columbus, Ohio Chapter 19, Chest Wall, Lung, Mediastinum, and Pleura
Chapter 45, Plastic and Reconstructive Surgery
Munier Nazzal, MD, MBA, CPE, FACS, FRCS
Tabitha G. Moe, MD, FACC Professor and Vice Chair, Department of Surgery
Assistant Professor of Surgery Chief, Division of Education
Adult Congenital Cardiology Chief, Division of Vascular, Endovascular and
Pulmonary Hypertension Wound Surgery.
Pregnancy and Cardiovascular Disease Medical Director of the Wound Center, University of
Creighton University School of Medicine Toledo Medical Center
Omaha, Nebraska University of Toledo
Chapter 20, Congenital Heart Disease Toledo, Ohio
Gregory L. Moneta, MD, FACS
Chapter 9, Wound Healing
Professor, Division of Vascular Surgery
Department of Surgery and Knight Cardiovascular
Institute
Oregon Health & Science University
Portland, Oregon
Chapter 24, Venous and Lymphatic Disease
xvi Matthew D. Neal, MD, FACS Mohamed F. Osman, MD
Roberta G. Simmons Assistant Professor of Surgery Assistant Professor of Surgery
Assistant Professor of Clinical and Translational Science Division of Vascular and Endovascular Surgery
and Critical Care Medicine Department of Surgery
Departments of Surgery Director of Surgical Intensive Care
Critical Care Medicine, and the Clinical and The University of Toledo College of Medicine and
Contributors
Translational Science Institute (CTSI) Life Sciences

University of Pittsburgh Toledo, Ohio
Attending Surgeon, Division of Trauma and Acute Care Chapter 9, Wound Healing
Surgery
Bradley Otto, MD
University of Pittsburgh Medical Center
Assistant Professor
Department of Otolaryngology—Head and Neck Surgery
Chapter 3, Fluid and Electrolyte Management of the
Division of Skull Base Surgery
Surgical Patient
Director, Division of General Otolaryngology
John Nemunaitis, MD Director, Division of Rhinology
Professor of Medicine The Ohio State University—James Comprehensive
Chief, Division of Hematology and Oncology Cancer Center
University of Toledo College of Medicine and Columbus, Ohio
Life Sciences Chapter 18, Disorders of the Head and Neck
Director Cancer Research
Adrian E. Park, MD, FRCSC, FACS, FCS(ECSA)
ProMedica Health System
Professor and Chairman
Toledo, Ohio
Anne Arundel Health System
Johns Hopkins University School of Medicine
Matt Niesen, MD Baltimore, Maryland
Clinical Instructor Chapter 34, The Spleen
Department of Orthopedic Surgery
Catherine C. Parker, MD, FACS
David Geffen School of Medicine at UCLA
Assistant Professor
The University of Alabama at Birmingham
John J. Nigro, MD Birmingham, Alabama
Chief, Pediatric Cardiac Surgery Chapter 17, The Breast
Director, Children’s Heart Center
Timothy M. Pawlik, MD, MPH, MTS, PhD, FACS,
Rady Children’s Hospital
San Diego, California RACS (Hon.)
Chapter 20, Congenital Heart Disease Professor and Chair
Junaid Nizamuddin, MD The Urban Meyer III and Shelley Meyer Chair for
Assistant Professor Cancer Research
Department of Anesthesia and Critical Care Surgeon-in-Chief
The University of Chicago The Ohio State University Wexner Medical Center
Chicago, Illinois Columbus, Ohio
Chapter 46, Anesthesia for Surgical Patients Chapter 48, Ethics, Palliative Care, and Care at the
Michael F. O’Connor, MD, FCCM End of Life
Professor Andrew B. Peitzman, MD
Department of Anesthesia & Critical Care Mark M. Ravitch Professor and Vice Chairman
The University of Chicago Department of Surgery, University of Pittsburgh School
Chicago, Illinois of Medicine
Chapter 46, Anesthesia for Surgical Patients Pittsburgh, Pennsylvania
Chapter 5, Shock
Raphael E. Pollock, MD, PhD, FACS Kara Richardson, MD xvii
Director, The Ohio State University Comprehensive Clinical Instructor
Cancer Center Department of Surgery
Professor of Surgery; Kathleen Klotz Chair in Cancer University of Toledo College of Medicine and
Research Life Sciences
The Ohio State University Wexner Medical Center Toledo, Ohio
Contributors
Columbus, Ohio Chapter 52, Ambulatory Surgery
Chapter 10, Oncology
Robert E. Roses, MD, FACS
Chapter 36, Soft Tissue Sarcomas
Matthew Pommerening, MD, MS Perelman School of Medicine
Department of Cardiothoracic Surgery University of Pennsylvania
University of Pittsburgh Medical Center (UPMC) Philadelphia, Pennsylvania
Pittsburgh, Pennsylvania Chapter 26, Stomach
Chapter 4, Hemostasis, Surgical Bleeding, and
Philip R. Schauer, MD
Transfusion
Professor of Surgery, Cleveland Clinic Lerner College of
Ourania Preventza, MD Medicine
Associate Professor, Michael E. DeBakey Department of Director, Bariatric and Metabolic Institute
Surgery Cleveland Clinic
Division of Cardiothoracic Surgery Cleveland, Ohio
Baylor College of Medicine Chapter 27, The Surgical Management of Obesity
Department of Cardiovascular Surgery,
Matthew R. Schill, MD
Texas Heart Institute
Clinical Instructor
Baylor St. Luke’s Medical Center, Houston, Texas
Division of Cardiothoracic Surgery Department of
Chapter 22, Thoracic Aneurysms and Aortic Dissection
Surgery
Jonathan Pribaz, MD Washington University School of Medicine
Resident in Orthopaedic Surgery Barnes-Jewish Hospital
UCLA Department of Orthopaedic Surgery St Louis, Missouri
Santa Monica, California Chapter 21, Acquired Heart Disease
Andrew B. Schneider, MD, MS
Raymond R. Price, MD, FACS The University of Chicago Medicine
Director, Graduate Surgical Education, Intermountain Chicago, Illinois
Medical Center, Intermountain Healthcare Chapter 51, Understanding, Evaluating, and Using
Director, Center for Global Surgery, Professor Evidence for Surgical Practice
Department of Surgery, University of Utah
Steven A. Schulz, MD
Salt Lake City, Utah
Assistant Professor, Department of Plastic and
Reconstructive Surgery
Carla M. Pugh, MD, PhD The Ohio State University Wexner Medical Center
Professor of Surgery Columbus, Ohio
Director, Technology Enabled Clinical Improvement Chapter 45, Plastic and Reconstructive Surgery
Center
Neal E. Seymour, MD, FACS
Stanford University
Vice Chair for Clinical Affairs, Department of Surgery
Palo Alto, California
Division Chief, General Surgery, Baystate Health
Chapter 53, Skills and Simulation
Professor and Surgery Residency Program Director
Ashwin G. Ramayya, MD, PhD University of Massachusetts Medical School—Baystate
Department of Neurosurgery Director, Baystate Simulation Center—Goldberg
Perelman School of Medicine at University of Surgical Skills Lab
Pennsylvania Springfield, Massachusetts
Philadelphia, Pennsylvania Chapter 53, Skills and Simulation
Chapter 42, Neurosurgery
xviii Joseph Sferra, MD, FACS Stephen Stanek, MD
Clinical Associate Professor of Surgery Clinical Assistant Professor of Surgery
University of Toledo College of Medicine and University of Toledo College of Medicine and
Life Sciences Life Sciences
Vice President Department of Surgery Department of Surgery
Promedica Health System Promedica Health System
Contributors
Toledo, Ohio Toledo, Ohio

Chapter 37, Inguinal Hernias Chapter 37, Inguinal Hernias
Ahmad Shabsigh, MD, FACS David B. Stewart, MD, FACS, FASCRS
Assistant Professor Section Chief, Colorectal Surgery
Department of Urology University of Arizona – Banner University Medical
The Ohio State University Center
Columbus, Ohio Tucson, Arizona
Chapter 40, Urology Chapter 29, Colon, Rectum, and Anus
Mark L. Shapiro, MD, FACS Anne M. Suskind, MD, FACS
Trauma Medical Director and Chief of Trauma Associate Professor of Urology
Grady Memorial Hospital Department of Urology
Emory University Department of Surgery University of California San Francisco
Atlanta, Georgia San Francisco, California
Chapter 12, Quality, Patient Safety, Assessments of Care, Chapter 47, Surgical Considerations in Older Adults
and Complications
Eduardo M. Targarona, MD, PhD, FACS
Saurabh Sinha, MD Chief of the Unit of Gastrointestinal and Hematological
Department of Neurosurgery Surgery, Hospital Sant Pau
Perelman School of Medicine at University of Professor of Surgery,
Pennsylvania Autonomous University of Barcelona
Philadelphia, Pennsylvania Barcelona, Spain
Chapter 42, Neurosurgery Chapter 34, The Spleen
Katherine E. Smiley, MD Ali Tavakkoli, MD
University of Utah Health Division of General and GI Surgery
Division of General Surgery Brigham and Women’s Hospital
Salt Lake City, Utah Associate Professor of Surgery
Chapter 49, Global Surgery Harvard Medical School
Boston, Massachusetts
David H. Song, MD, MBA, FACS
Physician Executive Director
MedStar Plastic & Reconstructive Surgery Theodoros N. Teknos, MD, FACS
Professor and Chairman Professor of Otolaryngology-Head and Neck Surgery
Department of Plastic Surgery President and Scientific Officer of UH Seidman
Georgetown University School of Medicine Cancer Center
Washington, DC UH Cleveland Medical Center
Chapter 16, The Skin and Subcutaneous Tissue Cleveland, Ohio
Michael W. Sourial, MD, FRCSC
Fellow, Endourology and Minimally Invasive Surgery Sarah M. Temkin, MD
Department of Urology Division of Gynecologic Oncology
The Ohio State University Virginia Commonwealth University
Columbus, Ohio Richmond, Virginia
Chapter 40, Urology Chapter 41, Gynecology
Donn H. Spight, MD Bert J. Thomas, MD
Assistant Professor Professor and Chief, Joint Replacement Service
Department of Surgery Department of Orthopedic Surgery
Oregon Health and Science University David Geffen School of Medicine at UCLA
Portland, Oregon Los Angeles, California
Chapter 14, Minimally Invasive Surgery, Robotics, Chapter 43, Orthopedic Surgery
Natural Orifice Transluminal Endoscopic Surgery, and
Single-Incision Laparoscopic Surgery
Allan Tsung, MD Ximo Wang, MD, PhD xix
UPMC Professor of Surgery Professor of Surgery
Division of Hepatobiliary and Pancreatic Surgery Department of Surgery
University of Pittsburgh Tianjin Medical University, Nankai Hospital
Pittsburgh, Pennsylvania Chief, Institute of Acute Abdomen of Tianjin
Chapter 31, Liver Tianjin, China
Contributors
Kiran K. Turaga, MD, MPH
Vice Chief, Section of General Surgery and Surgical
Oncology Zhiliang Wang, MD
Associate Professor, Department of Surgery Professor of Surgery
Director, Surgical GI Cancer Program Institute of Hepatobiliary Diseases
Director, Regional Therapeutics Program Zhongnan Hospital of Wuhan University
The University of Chicago Medical Center Hubei Providence, China
Chicago, Illinois Institute of Acute Abdomen of Tianjin
Chapter 30, The Appendix Tianjin, China
Jeffrey Upperman, MD
Director of Trauma, Pediatric Surgery David I. Watson, MBBS, MD, PhD, FRACS,
Children’s Hospital Los Angeles FRCSEd (Hon.), FAHMS
Keck School of Medicine Professor & Head, Discipline of Surgery
University of Southern California Flinders University of South Australia
Los Angeles, California Adelaide, South Australia
Chapter 39, Pediatric Surgery Australia
Ian L. Valerio, MD Chapter 25, Esophagus and Diaphragmatic Hernia
Professor, Department of Plastic and Reconstructive Randal S. Weber, MD, FACS
Surgery Professor and Chairman, Director of Surgical Services
The Ohio State University Wexner Medical Center Department of Head and Neck Surgery
Columbus Ohio University of Texas MD Anderson Cancer Center
Chapter 45, Plastic and Reconstructive Surgery Houston, Texas
Frank J. Veith, MD Chapter 18, Disorders of the Head and Neck
Professor of Surgery Adam S. Weltz, MD
Department of Surgery Department of Surgery
New York University Langone Health Anne Arundel Medical Center
New York, New York Annapolis, Maryland
Chapter 23, Arterial Disease Chapter 34, The Spleen
Dharmesh Vyas, MD, PhD John A. Windsor, BSc, MD, FRACS, FACS, FRSNZ
University of Pittsburgh Medical Center Orthopaedic HBP/Upper GI Surgeon and Professor of Surgery
Surgery Director, Surgical and Translational Research Centre
UPMC Lemieux Sports Complex Department of Surgery, University of Auckland,
Medical Director and Head Team Physician Auckland, New Zealand
Pittsburgh Penguins Chapter 33, Pancreas
Chapter 43, Orthopedic Surgery Juehua Yu, PhD
Associate Professor
Kasper Wang, MD Cancer Research Institute, Hangzhou Cancer Hospital,
Associate Professor of Surgery Hangzhou
Keck School of Medicine Department of Child Health Care, Xinhua Hospital
University of Southern California Shanghai JiaoTong University School of Medicine
Los Angeles, California Shanghai, China
Chapter 39, Pediatric Surgery Chapter 15, Molecular Biology, The Atomic Theory of
xx Michael E. Zenilman, MD, MS Brian S. Zuckerbraun, MD, FACS
Professor of Surgery Henry T. Bahnson Professor of Surgery
Weill Cornell Medicine University of Pittsburgh
Chair, Department of Surgery Chief, Trauma and General Surgery
New York Presbyterian Brooklyn Methodist Hospital University of Pittsburgh Medical Center and VA
Brooklyn, New York Pittsburgh Healthcare System
Contributors
Chapter 54, Web-Based Education and Implications of Pittsburgh, Pennsylvania

Social Media Chapter 5, Shock
Michael J. Zinner, MD, FACS
Moseley Professor of Surgery, Emeritus
Harvard Medical School
Boston, Massachusetts
CEO and Executive Medical Director
Miami Cancer Institute
Miami, Florida
First Foreword
It was a singular privilege to serve as editor-in-chief to maintain protect the unclosed abdominal abdomen for
of the first and subsequent six editions of Principles of protected state for a critical, at times prolonged, period
Surgery. The invitation from the current editor-in-chief, of time, during which caloric requirements are satisfied
Dr. F. Charles Brunicardi, who has discharged that parenterally.
responsibility for the ensuing four editions, to participate In oncology, a more precise tumor classification
in the textbook’s 50th anniversary, is gratifying. The based on size, nodal involvement, metastases, chemical
readers of the first seven editions often commented on the and biologic characteristics has been accepted. This, in
distinctive yellow cover. On this particular celebration of turn, has allowed for more meaningful assessment of
longevity, the color yellow connotes “gold.” a variety of therapeutic regimens. Chemotherapy has
The past 50 years has witnessed an unimaginable been joined by immunotherapy, and targeted, precision
growth in scientific knowledge available to students of genomic therapy has recently been introduced.
surgery. The “science of surgery” has gained dominance At the time of publication of the first edition of
over the “art of surgery.” Diverse technologies have been Principles of Surgery, only the kidney was deemed
incorporated to expedite diagnosis and improve surgical clinically acceptable for homotransplantation and
excision or repair. The establishment of more precise satisfactory immunosuppression had not been developed.
criteria for categorization and analyzing data, coupled Advances in immunosuppression have added the liver,
with advances in informatics, has allowed for the practice pancreas, small bowel, heart, and lungs to the list of
of “evidence-based medicine and surgery.” It is, as if, organs transplanted with anticipated success.
today’s surgeons have adopted a new language, new Among the 1805 pages of text in the first edition,
rules, new protocols—and anticipate new outcomes. The “facts” and “declarations by experts” have failed to stand
passage of time has been associated with transformative the test of time for a variety of reasons. Little effort is
change, which has been beautifully captured in the required to uncover statements that now would be judged
11th edition. “False!” For example: (1) Cancer of the hypopharynx is
Among the “Basic Considerations” that transcend three to four times as common as cancer of the larynx
individual organ systems, change has occurred at an (the reverse is true). (2) Effective treatment of a single
ever-accelerating pace, in multiple arenas, with variable ventricle in a neonate is not feasible. (3) The distal 1 to 2 cm
consequences, since the first edition made its debut. Not of the esophageal lumen is normally lined by columnar
all changes have been favorable. Increased effectiveness rather than squamous epithelium (the description of a
of antibiotics has improved the outcomes of the treatment Barrett’s esophagus). (4) There is but one treatment for
of sepsis, but has been associated with the appearance of acute appendicitis…the only question to be resolved is
c. difficile colitis and lethal MRSA hospital outbreaks. the timing of surgical intervention. (5) The adenomatous
HIV, AIDS, HPV (human papilloma virus), and hepatitis (colonic) polyp is a lesion of negligible malignant
B and C had not entered the surgical lexicon prior to potential. (6) The only acceptable treatment for a splenic
publication of Principles of Surgery. injury accompanied by any evidence of intraperitoneal
Over the course of years, trauma has become an bleeding in an adult is splenectomy. (7) Hundred percent
ever-increasing problem. Since publication of the first of patients with primary hyperaldosteronism have
edition, improved diagnostic techniques have altered the hypokalemia (most have no hypokalemia). More dramatic
approach to individuals who sustained major trauma. The is the evidence that many of the prevalent surgical
concept of immediate “damage control to be followed procedures that merited detailed illustration, consuming
by delayed definitive treatment,” the availability of multiple pages in the first edition, are now, rarely if ever,
angioembolization to control bleeding, and inert material performed.
xxii It must be emphasized that a textbook chronicles beautifully written 11th edition that carries forward
a science during the contemporaneous time. The first the tradition of the Principles of Surgery into the next
edition, as is true for each of the 11 editions of Principles 50 years.
of Surgery, is a compendium that pertains, solely, up to
the time of publication. Print does not imply permanence. Seymour I. Schwartz, MD, FACS
Print often outlasts the fact it promulgates. I congratulate Distinguished Alumni Professor of Surgery
Dr. Brunicardi and the coeditors on a modern and University of Rochester School of
Foreword
Medicine & Dentistry

Second Foreword
It is both an honor and a privilege to be asked to become the evidence and vetted by one or more senior surgeons
an associate editor for the 11th edition of Schwartz’s serving as editors. This new edition continues to provide
Principles of Surgery. Much has changed since the first up-to-date information on age-old topics in surgery such
edition was published in 1969, particularly in terms of how as the physiologic basis of disease as well as on the
adult learners obtain knowledge. Today, approximately nine clinical diagnosis and management of surgical diseases.
out of ten American adults use the internet and internet use The 11th edition deftly balances core knowledge that
by college graduates is nearly universal. Journal articles on has stood the test of time with contemporary advances
any and all topics are available with a few keystrokes, with in science and technology. Examples include updated
over 1,000 new articles being added daily to archives such chapters on “Molecular Biology, The Atomic Theory of
as PubMed Central. Additionally, there are a multitude of Disease, and Precision Surgery” and “Minimally Invasive
online textbooks, videos of procedures, interactive surgical Surgery, Robotics, and Natural Orifice Transluminal
simulator applications, and other web-based resources that Endoscopic Surgery.” Additionally, there are multiple
are widely available to medical students and professionals. chapters focused on non-technical skills, which are often
So, one might ask, do we still need surgical textbooks? more important than technical skills, such as the first
The debate about whether textbooks are obsolete chapter of the textbook on “Leadership in Surgery.” This
is not a new one. Opponents of textbooks suggest that 11th edition also boasts five new chapters: “Enhanced
they are expensive and inconvenient to access. Their Recovery after Surgery,” “Understanding and Evaluating
content can be argued to become quickly outdated and Evidence for Surgical Practice,” “Ambulatory/Outpatient
to be unengaging to the modern learner who prefers Surgery,” “Skills and Simulation,” and “Web-Based
interactive, multimedia content. On the other hand, Education and Implications of Social Media.”
proponents of textbooks note that evidence is lacking The fact that the 11th edition of Schwartz’s Principles
that comprehension is improved with digital technology. of Surgery marks the textbook’s 50th anniversary is a
Furthermore, textbooks allow teachers to provide content testament to its continued relevance and contributions
within a clear framework, to ensure uniform delivery of to surgical education. Moreover, its longevity is also a
content, and to have ease in re-referencing information. reflection of far-sighted editors-in-chief, first Dr. Seymour
What is the right answer? Modern and future learners Schwartz followed by Dr. F. Charles Brunicardi, who have
should have textbooks available to them in multiple media been able to not only keep up with but also to anticipate
formats. One media type does not fit all learners. Like changes in the surgical landscape. Not only is surgery a
surgery, optimal learning must be personalized based on continuously changing discipline, but also the world
an individual’s preferences. The editors and publishing in which surgeons practice is constantly evolving, as
company behind Schwartz’s Principles of Surgery have reflected by the digital era. Nonetheless, textbooks and the
embraced this idea—the hardcover continues to be the knowledge they carry will continue to play an important
best-selling general surgery textbook worldwide and role, regardless of their format and packaging.
there are no plans to eliminate the printed version. At the
same time, the content is widely available on an interactive Lillian S. Kao, MD
digital platform—Access Surgery—that includes access Jack H. Mayfield, MD, Chair in Surgery
to multiple textbooks, quick references, a video atlas, and Professor and Chief, Division of Acute Care Surgery
test review questions. Vice Chair of Research and Faculty Development
Regardless of the format, knowledge must come Vice Chair of Quality of Care
from a reliable source of information. For example, Co-Director, Center for Surgical Trials and
each chapter in the 11th edition of Schwartz’s Principles Evidence-based Practice (C-STEP)
of Surgery is written by at least one, and often two or Department of Surgery
more, authors who are experts in the subject matter. These McGovern Medical School at the
authors have frequently built on work by those who have University of Texas Health Science Center at Houston
preceded them. Furthermore, each chapter is supported by
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Preface
With the publication of its 11th edition, Schwartz’s have been added: Understanding and Evaluating Evidence
Principles of Surgery celebrates its 50th anniversary. It is for Surgical Practice, Enhanced Recovery after Surgery,
remarkable to consider the number of students, residents, Ambulatory/Outpatient Surgery, Skills and Simulation,
fellows, surgeons, and patients who have benefitted from and Web-based Education and Implications of Social
the collective knowledge compiled in this text over the last Media. This edition contains the latest in leadership
half-century. It is an honor for the current editorial board training, surgical science, surgical techniques, and therapy
to carry forward the tradition of excellence in education for students, residents, fellows, and surgeons. Another
established by Dr. Seymour Schwartz and previous editors. important component of this new edition is the artwork.
We recognize that surgeons have entered into an era of We acknowledge the outstanding artistic team of Jason M.
surgery in which the outcomes of operations and patient McAlexander & Associates who directed the full color art
satisfaction scores are carefully monitored, demanding program, which provides clear and consistent learning aids
excellence through enhanced evidenced-based knowledge, throughout the text and visually reflects the comprehensive
patient-family–centered care, and the highest levels of and updated nature of this book.
professionalism. The editors are thankful that this text is a trusted
The first chapter on leadership has taken on special source for training and crafting surgeons worldwide. Such
meaning in light of the new demands placed on surgeons success is due in large part to the extraordinary efforts
for both technical and nontechnical skills, underscoring of our contributors—leaders in their fields—who not
the importance of instituting a formal leadership-training only train up-and-coming surgeons but also impart their
program for surgery students of all ages with an emphasis knowledge and expertise to benefit patients across the
on mentoring. We have also entered into the dawn of a globe. The inclusion of many international authors to the
new era of surgery with advances in minimally invasive chapters within is ultimately a testament to mentorship,
surgery using robots, molecular contrast, and full albeit on a broader scale, and we thank these authors
computerization, thus enhancing the safety of surgery and mentors, both near and far. To our fellow editorial
and allowing surgeons a more comfortable environment board members who have tirelessly devoted their time
in which to work. We recognize that the use of “omic” and knowledge to the integrity and excellence of their
information is ushering in an era of precision surgery craft and this textbook, we extend our gratitude. We are
and the importance of surgeons, who have access to the thankful to Andrew Moyer, Christie Naglieri, and all at
tissues of the human body on a daily basis for “omic” McGraw-Hill who continued to believe in and support
profiling that will guide targeted therapies to enhance the this work, and we wish to thank Katie Elsbury for her
outcomes of surgery. dedication to the organization and editing of this edition.
Taking these constructs into consideration, the editors Lastly, we would like to thank our families for their
and authors of this 11th edition have done their very best support and love.
to revise each chapter and convey the current state-of-the-
art in surgery. Continuing in this effort, five new chapters F. Charles Brunicardi, MD, FACS
Dedication
We, the editors of this leading textbook of surgery,

Schwartz’s Principles of Surgery are pleased to dedicate
the 11th edition to Dr. Frank Gordon Moody. While
most academic surgeons recognize Dr. Moody, as a top
echelon surgical leader of the last half century, we choose
to dedicate this edition to him because of the profound
influence he had on the careers of many of the editors
of this textbook. To some of us, Dr Moody was our
surgical chair and academic inspiration. To others he was
a research collaborator. For those of us who are not direct
descendants, academically speaking, Frank Moody had
the ability to recognize and provide the gift of mentorship
to talented academic surgeons, irrespective of their
academic pedigree.
Dr. Moody was born in Franklin, New Hampshire,
attended Dartmouth College and Dartmouth Medical
School (when it was a two-year school) then received
his MD from Cornell. He stayed at Cornell throughout Reprinted with permission of The University of Texas Health
his surgical training, enticed into upper GI surgery by Science Center at Houston, © 2008.
Dr. Frank Glenn. His academic career started at the
University of California, San Francisco, under the legendary to have Dr. Moody engage with their line of discovery.
leadership of Dr. Bert Dunphy. He was subsequently Nearly continuously funded by the National Institutes of
recruited to the University of Alabama, Birmingham, Health (NIH) from 1967 to 2008, Dr. Moody was a force
where he rose to the rank of professor. In 1971, he became for surgical science, encouraging active participation by
the Chair of Surgery at the University of Utah, coupling surgeons in the NIH study sections.
his love for skiing and hiking with an intense desire to To many of the editors, the connection to Dr. Moody
bring scientific inquiry to the Wasatch Front. There, his was even more personal. Attracted to training in Utah by
passion for mentorship was uncovered. Eight of his the combination of skiing, science, and great surgical
trainees became department chairs, and many more visited training, I first met Dr. Moody in the pages of the
Utah where the academic ‘bug’ was inoculated. In 1982, 3rd edition of this textbook, in which he authored the
Dr. Moody took his talents to the University of Texas, chapter on gallbladder disease. After many years of learning
Houston, where he served as the Denton Cooley Chair of in the operating room and the laboratory, it is an honor to
Surgery. While he stepped down as Chair 12 years later, follow in his footsteps as the author of this chapter in this
Dr. Moody remained in Texas for the rest of his career. and the prior three editions of this classic surgical book.
Dr. Moody’s influence was truly global; he was active in Dr. Moody, we will miss you, and hope to carry your many
the International Surgical Society and was a founder of the gifts forward, the greatest of which were your support and
International Surgical Group. It was often said that there mentorship of the many who have been lucky enough to
was never a meeting that Dr. Moody missed–and at every follow in your footsteps.
meeting he truly “showed up”, contributing to the program,
asking challenging questions, and spurring new lines of John G. Hunter MD and the editors of
investigation for the many GI surgeons lucky enough Schwartz’s Principles of Surgery, 11th edition
Basic Considerations
Part I
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1
Leadership in Surgery
Stephen Markowiak, Hollis Merrick, Shiela Beroukhim,
chapter Jeremy J. Laukka, Amy Lightner, Munier Nazzal,
Lee Hammerling, James R. Macho, and
F. Charles Brunicardi
Introduction 3 Choosing to Become a Leader / 11 Evaluation of Surgeon Performance / 16

Definitions of Leadership 3 Leadership’s Effect on Healthcare Cost Mentoring and Development 18
Levels of Leadership / 4 and Clinical Outcomes / 11 Mentoring / 18
The Importance of Diversity and Modeling Leadership for Medical Students
Fundamental Principles of Leadership 12
Leadership 4 and the “Hidden Curriculum” / 18
Vision / 5 Leadership Styles 12 Tools to Measure Leadership Outcomes in
Generating Belief in Your Vision / 6 Formal Leadership Training Healthcare / 19
Willingness / 7 Programs in Surgery 13 Leadership Training for the
Time Management / 10 History of Leadership Training and Prospective Surgeon / 20
the Multifactor Leadership Early Career Development and
Self-Care and Wellness / 11
Questionnaire / 13 Establishing Oneself 20
Recruitment / 11
Designing the Program / 14
Creating a Culture of Empathy, Senior Faculty Development:
Practicing Leadership Skills and Assessing
Patient-Family-Centered Care, and Transitioning to Departmental
Leadership Formally With Objective
Personalized Surgery / 11 Leadership and Legacy Building 21
Structured Clinical Examination (OSCE)
Why We Lead 11 and Simulation / 14 Conclusion 21
INTRODUCTION formal curricula focused on teaching leadership principles, it is

now imperative that all surgical training programs teach these
The field of surgery has evolved greatly from its roots, and sur-
important skills to their trainees.4,5 Interviews of academic
gical practice now requires the mastery of modern leadership
chairpersons identified several critical leadership success
principles and skills as much as the acquisition of medical
factors,6 including mastery of visioning, communication, change
knowledge and surgical technique. Historically, surgeons took
management, emotional intelligence, team building, business
sole responsibility for their patients and directed proceedings in
skills, personnel management, and systems thinking. These
the operating room with absolute authority, using a command-
chairpersons stated that the ability of emotional intelligence was
and-control style of leadership. Modern surgical practice has
“fundamental to their success and its absence the cause of their
now evolved from single provider–based care toward a team-
failures,” regardless of medical knowledge.6 Thus, residency
based approach, which requires collaborative leadership skills.
programs need to include leadership training to prepare future
Surgical care benefits from the collaboration of surgeons, anes-
surgeons for success in modern healthcare delivery.
thesiologists, internists, radiologists, pathologists, radiation
In the United States, the Accreditation Council for
oncologists, nurses, pharmacists, social workers, therapists,
Graduate Medical Education (ACGME) has established six
hospital staff, and administrators. Occupying a central role on
core competencies—patient care, medical knowledge, prac-
the healthcare team, surgeons1 have the potential to improve
tice-based learning and improvement, interpersonal and com-
patient outcomes, reduce medical errors, and improve patient
munication skills, professionalism, and systems-based practice
satisfaction through their leadership of the multidisciplinary
(Table 1-1)4—that each contain principles of leadership. The
team. Thus, in the landscape of modern healthcare systems, it is
ACGME has mandated the teaching of these core competencies
imperative that surgical training programs include formal
1 instruction on leadership principles and skills to cultivate but has not established a formal guide on how to teach the lead-
ership skills described within the core competencies. Therefore,
their trainees’ leadership capabilities.
this chapter offers a review of fundamental principles of leader-
Many medical and surgical communities, including
ship and an introduction of the concept of a leadership training
residency training programs, acknowledge the need for
program for future surgeons.
improved physician leadership. Specifically, surveyed surgical
residents felt a lack of confidence in multiple areas of leadership,
particularly in conflict resolution.2 Surgical trainees identify DEFINITIONS OF LEADERSHIP
leadership skills as important, but they report themselves as “not Many different definitions of leadership have been described.
competent” or “minimally competent” in this regard.2,3 While a Former First Lady Rosalynn Carter once observed that “A leader
small number of surgical training programs have implemented takes people where they want to go. A great leader takes people
Key Points
1 Effective surgical leadership improves patient care, safety, 5 Surgical leaders have the willingness to communicate effec-
and clinical outcomes. tively and resolve conflict.
2 A fundamental principle of leadership is to provide a vision 6 Surgical leaders must practice effective time management.
that people can live up to, thereby providing direction and 7 Different leadership styles are tools to use based on the team
purpose to the constituency. dynamic.
3 Surgical leaders have the willingness to lead through an 8 Surgical trainees can be taught leadership principles in formal
active and passionate commitment to the vision. leadership training programs to enhance their ability to lead.
4 Surgical leaders have the willingness to commit to lifelong 9 Mentorship provides wisdom, guidance, and insight essen-
learning. tial for the successful development of a surgical leader.
where they don’t necessarily want to go, but where they ought of business. In business, the processes of customer satisfaction,
to be.” Leadership does not always have to come from a position product development, and organization efficiency are the equiva-
of authority. Former American president John Quincy Adams lent of patient satisfaction, medical advancement, and efficient
stated, “If your actions inspire others to dream more, learn more, delivery of care. Jim Collins, author of Good to Great, studied
do more, and become more, you are a leader.” Another defini- the success and leadership styles of Fortune 500 companies over
tion is that leadership is the process of using social influence to a 30-year period. He found that leadership is strongly correlated
enlist the aid and support of others in a common task.7 with corporate success, and most importantly for our study, that
leadership strength can be broken down by level and characteristic
Levels of Leadership (See figure 1-1).8
When working toward organizational success, strong leader- Of 11 particularly outstanding organizations identified,
ship is a critical component. The best study of the relationship great leadership was the single major defining characteristic that
between leadership skill and organizational success is in the field distinguished them from their peers. These organizations were
led by what Collins called the “Level 5 Leader,” one whose per-
Table 1-1 sonal humility and professional will drove team success. Under
this system of leadership study, surgeon-leaders begin at the
Accreditation Council for Graduate Medical Education
bottom level and, through study, hard work, and professional
core competencies development, advance to the ultimate level of leadership.8
CORE COMPETENCY DESCRIPTION
Patient care To be able to provide compassionate FUNDAMENTAL PRINCIPLES OF LEADERSHIP
and effective healthcare in the Leadership is a complex concept. Surgeons should strive to
modern-day healthcare environment adopt leadership qualities that provide the best outcomes for
Medical To effectively apply current medical their patients, based on the following fundamental principles:
knowledge knowledge in patient care and to vision, willingness, time management, conflict resolution,
be able to use medical tools (i.e.,
PubMed) to stay current in medical LEVEL 5 EXECUTIVE
education Builds enduring greatness
Practice-based To critically assimilate and evaluate through a paradoxical combination
of personal humility plus professional will.
learning and information in a systematic manner to
improvement improve patient care practices LEVEL 4 EFFECTIVE LEADER
Interpersonal and To demonstrate sufficient Catalyzes commitment to and vigorous pursuit
of a clear and compelling vision; stimulates
communication communication skills that allow for the group to high performance standards.
skills efficient information exchange in
physician-patient interactions and as LEVEL 3 COMPETENT MANAGER
a member of a healthcare team Organizes people and resources toward the effective
and efficient pursuit of predetermined objectives.
Professionalism To demonstrate the principles of ethical
behavior (i.e., informed consent, LEVEL 2 CONTRIBUTING TEAM MEMBER
patient confidentiality) and integrity Contributes to the achievement of group
objectives; works effectively with others in a group setting.
that promote the highest level of
medical care LEVEL 1 HIGHLY CAPABLE INDIVIDUAL
Systems-based To acknowledge and understand that Makes productive contributions through talent, knowledge,
skills, and good work habits.
practice each individual practice is part of
a larger healthcare delivery system
and to be able to use the system to Figure 1-1. Levels of leadership as defined by Jim Collins in Good
to Great. (Reproduced with permission from Collins J: Good to
support patient care
4 Great. Boston, MA: Harper Collins; 2011.)
Table 1-2 5
The fundamental principles of leadership
CHAPTER 1
DESCRIPTION AND APPLICATION IN THE
LEADERSHIP SKILL FIELD OF MEDICINE
Vision The act of establishing tangible goals of
care for patients on both a daily basis
as well as for long-term purposes.
LEADERSHIP IN SURGERY
Effective Establishing an open, respectful,
communication and nonjudgmental forum for
communication among different
members of the healthcare team and
with the patient.
Willingness to Taking on full responsibility for the care Figure 1-2. Apollo 11 Lunar Module moon walk. Astronaut
lead of patients and remaining ethical, Edwin “Buzz” Aldrin walks by the footpad of the Apollo 11 Lunar
Module, July 1969. (Reproduced with permission from AP Photo/
professional, and committed despite
NASA. © 2018 The Associated Press.)
the especially challenging rigors of
joining the field of surgery.
rate at that time, using carbolic acid dressings and aseptic
Willingness to A commitment to lifelong learning of
surgical technique. The boy recovered, and Lister gathered nine
learn the latest scientific, medical, and
more patients. His famous publication on the use of aseptic
surgical updates to deliver optimized
technique introduced the modern era of sterile technique. Emil
patient care.
Theodor Kocher was the first to master the thyroidectomy,
Conflict The art of resolving conflicts in a thought to be an impossible operation at the time, and went on
resolution peaceful and ethical manner in team to perform thousands of thyroidectomies with a mortality of
settings. less than 1%. He was awarded the Nobel Prize in Physiology or
Medicine in 1909 for describing the thyroid’s physiologic role
recruitment, and culture (See Table 1-2). Surgeon-leaders will in metabolism. Michael E. DeBakey’s powerful vision led to
develop a team of faculty, residents, and other healthcare per- the development of numerous groundbreaking procedures that
sonnel who are aligned on mission, vision, and values. The team helped pioneer the field of cardiovascular surgery. For example,
and leader must be willing to address complex problems with envisioning an artificial artery for arterial bypass operations, Dr.
honest communication and well-developed conflict resolution DeBakey invented the Dacron graft, which has helped millions
skills. A culture must be established where faculty and staff of patients suffering from vascular disease and enabled the
will work towards the advancement of the medical arts and the development of endovascular surgery. Dr. Frederick Banting,
greater good of society.9 the youngest recipient of the Nobel Prize in Physiology or
Medicine, had a vision to discover the biochemical link between
Vision diabetes and glucose homeostasis. His vision and perseverance
The first and most fundamental principle of leadership is to led to the discovery of insulin.11 In retrospect, the power and
establish a vision that people can live up to, thus providing clarity of their visions were remarkable, and their willingness
direction and purpose to the constituency. Creating a vision is a and dedication were inspiring. By studying their careers and
declaration of the near future that inspires and conjures accomplishments, surgical trainees can be inspired by the
motivation.10 A classic example of a powerful vision that potential impact of a well-developed vision.
2 held effective impact is President Kennedy’s declaration
in 1961 that “. . . this nation should commit itself to achieving
the goal, before this decade is out, of landing a man on the moon
and returning him safely to the earth.” Following his declaration
of this vision with a timeline to achieve it, the United Sates
mounted a remarkable unified effort, and by the end of the
decade, Neil Armstrong took his famous walk and the vision
had been accomplished (Fig. 1-2).
On a daily basis, surgeons are driven by a powerful vision:
the vision that our surgical care will improve patients’ lives.
The great surgical pioneers, such as Hunter, Lister (Fig. 1-3),
Halsted, von Langenbeck, Billroth, Kocher (Fig. 1-4), Carrel,
Gibbon, Blalock, Wangensteen, Moore, Rhoads, Huggins,
Murray, Kountz, Longmire, Starzl, and DeBakey (Fig. 1-5), each
possessed a vision that revolutionized the field of surgery. In the
19th century, Joseph Lister changed the practice of surgery with Figure 1-3. Joseph Lister directing use of carbolic acid spray
his application of Pasteur’s germ theory. He set a young boy’s in one of his earliest antiseptic surgical operations, circa 1865.
open compound leg fracture, a condition with a 90% mortality (Used with permission from Getty Images.)
6 Generating Belief in Your Vision
Surgical leaders with great visions will inevitably require help
from colleagues, other healthcare professionals, scientists,
administrators, patients, and nonmedical personnel. To get this
help, surgical leaders must inspire their team and understand
PART I
motivation. For the surgeon-leader, it is critical to know that

people do not follow leaders because of what they do; people
follow leaders because of why they do what they do. The people
who help the leader execute the vision are motivated by the
leader’s beliefs and attitudes more than the leader’s policy or
BASIC CONSIDERATIONS
agenda. This concept, based on Simon Sinek’s Start With Why,

is rooted in understanding of the anatomy and function of the
human brain.13 See figure 1-6.
For example, take a surgeon-leader who wants to imple-
ment a new perioperative checklist to reduce surgical errors. The
“what” is very simple: a checklist to reduce errors. The operating
room team may make a rational decision to adapt the checklist;
however, it is also possible that the checklist may be perceived as
“another piece of paperwork” and rejected, or that the checklist
may have its implementation fought, undermined, delayed, or
ignored. A surgeon-leader who does not understand how people
are motivated might argue rationally, telling the team that the
checklist was created with great care, that all of the best evidence
was incorporated in its creation, and that the checklist is short
and efficient. This is the “how,” and once again it appeals to the
rational and analytical side of the team. With these arguments,
the surgeon-leader’s vision remains susceptible to rejection for
Figure 1-4. Emil Theodor Kocher. (Reproduced with permission many of the same reasons. A leader who understands how to
from the National Library of Medicine.) motivate a team towards a vision will start with “why.” Before
ever discussing the checklist in detail with the team, the leader
will speak of their shared mission to offer the best patient care
Leaders must learn to develop a vision to provide direction possible, ask the team to imagine how they might want a family
for their team. The vision can be as straightforward as provid- member treated, and emphasize that a careless error could lead to
ing quality of care or as lofty as defining a new field of sur- patient harm and embarrassment for the team. With these argu-
gery, such as atomic surgery and personalized medicine. One ments, which constitute an emotional appeal to the team’s belief
can start developing such vision by brainstorming the answers system, the leader can expect this vision for better patient care
to two simple questions: “Which disease needs to be cured?” via a new surgical checklist to be adapted by the team. The team
and “How can it be cured?”12 The answers represent a vision will be receptive to implementing a new checklist, not because
and should be recorded succinctly in a laboratory notebook or they believe in the checklist as a tool, but because they believe in
journal. Committing pen to paper enables the surgical trainee the surgeon-leader’s vision for optimizing patient care.
to define his or her vision in a manner that can be shared with There is a biological reason why this concept works.
others. “Why,” “how,” and “what” are correlated to the functions
What
Neocortex
How
Why Limbic Brain
When a leader's vision appeals to “why,” it triggers an emotional

response in the limbic brain and increases the likelihood that a
vision will be embraced. Persuasion using “what” and “how”
appeals to the neocortex and is more easily rejected.
Figure 1-6. When leaders seek to generate belief in their vision,

it is best to appeal to the team with “why” statements. (Data from
Figure 1-5. Michael E. DeBakey. (Reproduced with permission Sinek S. Start with why: how great leaders inspire everyone to take
from AP Photo/David J. Phillip. © 2018 The Associated Press.) action. London: Portfolio/Penguin; 2013.)
7
The Flywheel Effect of Building and Sustaining
Momentum
WHAT YOU ARE DEEPLY
PASSIONATE ABOUT
CHAPTER 1
Steps
forward
Momentum Visible
WHAT YOU CAN WHAT DRIVES
builds results
BE THE BEST IN YOUR
THE WORLD AT ECONOMIC
ENGINE
The Team
aligns and
Figure 1-7. Leaders should be selective about where they expend adjusts
their efforts, as demonstrated by Jim Collins in “Good to Great.”
(Reproduced with permission from Collins J: Good to Great. Boston, Figure 1-8. The “flywheel effect.” (Data from Collins J: Good to
MA: Harper Collins; 2011.) Great. Boston, MA: Harper Collins; 2011.)
of separate anatomical levels in the human brain. The neo- Willingness

cortex is, evolutionarily, the newest area of our brains, and The Willingness Principle represents the active commitment of
it is responsible for the analytical and rational thoughts and the leader toward his or her vision. To do so, a surgical leader
decisions that we make. It corresponds to the “what” and the must be willing to lead, commit to lifelong learning, communi-
“how.” When the surgeon-leader in the previous example cate effectively, and resolve conflict.
started with the checklist and its rational arguments, the leader
was appealing to their team’s neocortex, and the vision was To Lead. A key characteristic of all great leaders is the will-
rejected. However, when the surgeon started with the “why,” ingness to serve as the leader. Dr. Martin Luther King Jr, who
the vision for better patient care was emotionally accepted by championed the civil rights movement with a powerful vision of
the team, who became receptive to the checklist as a tool for equality for all based on a commitment to nonviolent methods,14
achieving the vision.13 did so at a time when his vocalization of this vision ensured
Surgery is a field that requires extraordinary dedication and harassment, imprisonment, and threats of violence against him-
great personal sacrifice. The very nature of vision—steps forward self, his colleagues, and his family and friends (Fig. 1-9). King,
into a better future—implies that change and difficult work will a young, highly educated pastor, had the security of employ-
be required of the leader. See figure 1-7. For this reason, surgeon- ment and family, yet was willing to accept enormous respon-
leaders should establish visions about which they are deeply pas- sibility and personal risk and did so in order to lead a nation
sionate and committed so that when obstacles are encountered toward his vision of civil rights, for which he was awarded the
the leader has the strength of will to progress forward. Leaders Nobel Peace Prize in 1964.
should be selective about which options they pursue. Each oppor- Willingness to lead is a necessity in any individual who
tunity and idea requires great effort to execute; ultimately only desires to become a surgeon. By entering into the surgical the-
a few can be brought to completion. Therefore, leaders should ater, a surgeon accepts the responsibility to care for and operate
understand what drives their organization’s economic engine: on patients, despite the risks and burdens involved. They do so,
the ideas and opportunities that will bring patients better care, believing fully in the improved quality of life that can be
bring the organization more patients, and create new treatments, achieved. Surgeons must embrace the responsibility of leading
etc. Thousands of hospitals, companies, innovators, and physicians surgical teams that care for their patients, as well as leading sur-
are addressing many of the same problems in healthcare, such as gical trainees to become future surgeons. A tremendous sacrifice
growing burdens of chronic disease, an aging population, and ris- is required for the opportunity to learn patient care. Surgical
ing health costs. The best opportunities lie where talent and ability trainees accept the hardships of residency with its accompanying
align, so leaders and organizations should be cognizant of choos- steep learning curve, anxiety, long work hours, and time spent
ing projects for which they have the potential to be the “best in away from family and friends. The active, passionate commit-
the world” at doing. Once the vision is set and the project is ment to excellent patient care reflects a natural willingness to
chosen, it is up to the leader to generate momentum. lead based on altruism and a sense of duty toward those receiving
Momentum is either a cumulative effect of continuous care. Thus, to ensure delivery of the utmost level of care, surgical
steps towards improvement or, alternatively, in the negative trainees should commit to developing and refining leadership
sense, movements towards failure or stagnation. The “flywheel 3 skills. These skills include a commitment to lifelong learn-
ing, effective communication, and conflict resolution.
effect,” depicted in Fig. 1-8, demonstrates the building of
momentum with (a) initial steps forward, (b) an accumulation To Learn. Surgeons and surgical trainees, as leaders, must
of visible results, (c) realignment of the team in the new direc- possess willingness to commit to continuous learning. Modern
tion (accounting for new information and data), and then (d) an surgery is an ever-changing field with dynamic and evolving
accumulation of momentum followed by more steps forward. healthcare systems and constant scientific discovery and inno-
Careful attention to the aforementioned principles is essential in vation. Basic and translational science relating to surgical care
building a successful surgical career, department, or division.8 is growing at an exponential rate. The sequencing of the human
8 techniques, including the use of robotic surgery. The field con-
tinues to advance, offering many advantages to patients includ-
ing faster recovery, sometimes decreased pain depending on
procedure type, and shorter hospital stays.16-18
Fortunately, surgical organizations and societies provide
PART I
surgeons and surgical trainees a means to acquire new knowl-

edge on a continuous basis. There are numerous local, regional,
national, and international meetings of surgical organizations
that provide ongoing continuing medical education credits, also
required for the renewal of most medical licenses. The American
Board of Surgery requires all surgeons to complete meaningful

continuing medical education to maintain certification.19 These
societies and regulatory bodies enable surgeons and surgical
4 trainees to commit to continual learning and ensure their
competence in a dynamic and rapidly growing field.
Surgeons and trainees now benefit from the rapid expan-
sion of web-based education as well as mobile handheld tech-
nology. These are powerful tools to minimize nonproductive
time in the hospital and make learning and reinforcement of
medical knowledge accessible. Currently web-based resources
provide quick access to a vast collection of surgical texts, lit-
erature, and surgical videos. Surgeons and trainees dedicated
to continual learning should be well versed in the utilization
of these information technologies to maximize their education.
The next evolution of electronic surgical educational materials
will likely include simulation training similar to laparoscopic
and Da Vinci device training modules. The ACGME, acknowl-
edging the importance of lifelong learning skills and moderniza-
Figure 1-9. Dr. Martin Luther King Jr acknowledges the crowd at tion of information delivery and access methods, has included
the Lincoln Memorial for his “I Have a Dream” speech during the them as program requirements for residency accreditation.
March on Washington, D.C., August 28, 1963. (Reproduced with To Communicate Effectively. The complexity of modern
permission from AP Photo. © 2018 The Associated Press.) healthcare delivery systems requires a higher level and collab-
orative style of communication. Effective communication
directly impacts patient care. In 2000, the U.S. Institute of Medi-
genome and the enormous advances in molecular biology and cine published To Err Is Human: Building a Safer Health S ystem,
signaling pathways are leading to the transformation of pre- which raised awareness concerning the magnitude of medical
cision medicine and personalized surgery in the 21st century errors. This work showcased medical errors as the eighth leading
(see Chapter 15).15 Performing prophylactic mastectomies with cause of death in the United States with an estimated 100,000
immediate reconstruction for BRCA1 mutations and thyroidecto- deaths annually.20 Subsequent studies examining medical errors
mies with thyroid hormone replacement for RET proto-oncogene have identified communication errors as one of the most com-
mutations are two of many examples of genomic information mon causes of medical error.21-23 In fact, the Joint Commission
guiding surgical care. Technologic advances in minimally inva- identifies miscommunication as the leading cause of sentinel
sive surgery and robotic surgery as well as electronic records events. Information transfer and communication errors cause
and other information technologies are revolutionizing the craft delays in patient care, waste surgeon and staff time, and cause
of surgery. The expansion of minimally invasive and endovas- serious adverse patient events.23 Effective communication among
cular surgery over the past three decades required surgeons to surgeons, nurses, ancillary staff, and patients is not only a crucial
retrain in new techniques using new skills and equipment. In element to improved patient outcomes, but it also leads to less
this short time span, laparoscopy and endovascular operations medical litigation.24-26 A strong correlation exists between
are now recognized as the standard of care for many surgical 5 communication and patient outcomes.
diseases, resulting in shorter hospital stay, quicker recovery, and Establishing a collaborative atmosphere is important
a kinder and gentler manner of practicing surgery. Remarkably, since communication errors leading to medical mishaps are not
during the last century, the field of surgery has progressed at an simply failures to transmit information. Communication errors
exponential pace and will continue to do so with the advent of “are far more complex and relate to hierarchical differences,
using genomic analyses to engineer cancer cells with molecular concerns with upward influence, conflicting roles and role
imaging agents that will guide personalized surgery, which will ambiguity, and interpersonal power and conflict.”22,27-29 Errors
transform the field of surgery during this century. Therefore, frequently originate from perceived limited channels of com-
surgical leadership training should emphasize and facilitate the munication and hostile, critical environments. To overcome
continual pursuit of knowledge. these barriers, surgeons and surgical trainees should learn to
Willingness to learn encompasses the surgeon’s commit- communicate in an open, universally understood manner and
ment to lifelong learning. This has been exemplified by the remain receptive to any team member’s concerns. A survey
surgeons of the past several decades who have dedicated their of physicians, nurses, and ancillary staff identified effective
peak practicing years to perfecting minimally invasive surgical communication as a key element of a successful leader.30 As
leaders, surgeons, and surgical trainees who facilitate an open, modern surgical care is complex; numerous conflicts arise on 9
effective, and collaborative style of communication can reduce a daily basis when surgeons and surgical trainees provide high-
errors and enhance patient care. A prime example is that suc- quality care. Therefore, the techniques for conflict resolution are
cessful communication of daily goals of patient care from the essential for surgical leaders.
CHAPTER 1
team leader improves patient outcomes. In one recent study, To properly use conflict resolution techniques, it is impor-
the modest act of explicitly stating daily goals in a standard- tant for the surgeon and surgical trainee to always remain objec-
ized fashion significantly reduced patient length of intensive tive and seek personal flexibility and self-awareness. The gulf
care unit stay and increased resident and nurse understanding of between self-perception and the perception of others can be
goals of care.31 Implementing standardized daily team briefings profound; in a study of cooperation and collaboration among
in the wards and preoperative units led to improvements in staff operating room staff, the quality of their own collaboration was
turnover rates, employee satisfaction, and prevention of wrong- rated at 80% by surgeons, yet was rated at only 48% by oper-
site surgery.27 In cardiac surgery, improving communication in ating room nurses.44 Systematic inclusion of modern conflict
the operating room and transition to the postanesthesia care unit resolution methods that incorporate the views of all members of
was an area identified to decrease risk for adverse outcomes.32 a multidisciplinary team help maintain objectivity. Reflection is
Behaviors associated with ineffective communication, including often overlooked in surgical residency training, but it is a critical
absence from the operating room when needed, playing loud component of learning conflict resolution skills. Introspection
music, making inappropriate comments, and talking to others allows the surgeon to understand the impact of his or her actions
in a raised voice or a condescending tone, were identified as and biases. Objectivity is the basis of effective conflict resolu-
patient hazards; conversely, behaviors associated with effec- tion, which can improve satisfaction among team members and
tive collaborative communication, such as leading the time-out help deliver optimal patient care.
process and closed-loop communication technique, resulted in Modern conflict resolution techniques are based on objec-
improved patient outcomes. tivity, willingness to listen, and pursuit of principle-based solu-
One model to ensure open communication is through tions.45 For example, an effective style of conflict resolution
standardization of established protocols. A commonly accepted is the utilization of the “abundance mentality” model, which
protocol is the “time out” that is now required in the modern attempts to achieve a solution that benefits all involved and is
operating room. During the time-out protocol, all team mem- based on core values of the organization, as opposed to the uti-
bers introduce themselves and state a body of critical informa- lization of the traditional fault-finding model, which identifies
tion needed to safely complete the intended operation. This sides as right or wrong.46 Application of the abundance mental-
same standardization can be taught outside the operating room. ity in surgery elevates the conflict above the affected parties and
Within the Kaiser system, certain phrases have been given a uni- focuses on the higher unifying goal of improved patient care.
versal meaning: “I need you now” by members of the team is an “Quality Improvement” (previously or alternatively “Morbidity
understood level of urgency and generates a prompt physician and Mortality”) conferences are managed in this style and have
response 100% of the time.27 As mentioned earlier, standardized the purpose of practice improvement and improving overall
forms can be useful tools in ensuring universally understood quality of care within the system, as opposed to placing guilt or
communication during sign-out. The beneficial effect of stan- blame on the surgeon or surgical trainees for the complication
dardized team communication further demonstrates how effec- being reviewed. The traditional style of command-and-control
tive communication can improve patient care and is considered technique based on fear and intimidation is no longer welcome
a vital leadership skill. in any healthcare system and can lead to sanctions, lawsuits, and
Effective communication with patients in the mod- removal of hospital privileges or position of leadership.
ern era, necessitates understanding that many patients access Another intuitive method that can help surgical trainees
health information via the internet and that patients are often ill learn to resolve conflict is the “history and physical” model of
equipped to evaluate the individual source.33,34 Discrepancies conflict resolution. This model is based on the seven steps of
exist between surgeon’s self-perceived ability to communicate caring for a surgical patient that are well known to the surgical
and patient’s actual satisfaction. A patient’s perceived interac- trainee47: (a) the “history” is the equivalent of gathering subjec-
tion with their physician has an enormous impact on patient tive information from involved parties with appropriate empa-
health outcomes, malpractice, and financial reimbursement;35-40 thy and listening; (b) the “laboratory/studies” are the equivalent
specifically, the association between poor doctor–patient com- of collecting objective data to validate the subjective informa-
munication and a patient’s perception that their doctor does tion; (c) a “differential diagnosis” is formed out of possible root
not care about them. Good bedside manner has been shown to causes of the conflict; (d) the “assessment/plan” is developed in
decrease litigation even in situations of error or undesirable out- the best interest of all involved parties; the plan, including risks
come.39-40 Physicians who demonstrate concern, actively know and benefits, is openly discussed in a compassionate style of com-
their patients, and share responsibility for decision-making are munication; (e) “preoperative preparation” includes the acquisi-
more likely to be trusted by their patients.26,41,42 Strong doctor– tion of appropriate consultations for clearances, consideration
patient relationships and effective communication skills have of equipment and supplies needed for implementation, and the
been incentivized by the Agency for Healthcare Research and “informed consent” from the involved parties; (f) the “operation”
Quality and the Centers for Medicare & Medicaid Services is the actual implementation of the agreed-upon plan, including
through their Hospital Consumer Assessment of Healthcare a time-out; (g) and “postoperative care” involves communicat-
Providers and Systems (HCAHPS) and Clinical and Group ing the operative outcome, regular postoperative follow-up, and
Consumer Assessment of Healthcare Providers and Systems the correction of any complications that arise. This seven-step
(CGCAHPS) programs, which measure patient satisfaction.43 method is an example of an objective, respectful method of con-
To Resolve Conflict. Great leaders are able to achieve their flict resolution.47 Practicing different styles of conflict resolu-
vision through their ability to resolve conflict. Delivery of tion and effective communication in front of the entire group of
10 Time Motion Study
Low education High education
Low service
Low education, low High education, low

PART I
service value (Ex: Waiting during service value

mandatory in-house call) (Ex: Teaching conferences)
Low education,
High service
High education, high

high service value
service value
(Ex: Repeatedly performing
(Ex: Operating with a mentor)
History & Physicals)
Figure 1-10. Surgery resident time-motion study.
surgical trainees attending the leadership training program is an values to their tasks. The use of the lists and categories serves
effective means of teaching conflict resolution techniques. solely as a reminder, thus falling short of aiding the user in allo-
cating time wisely. Another technique is the “time management
Time Management matrix technique.”49 This technique plots activities on two axes:
It is important for leaders to practice effective time management. importance and urgency, yielding four quadrants (Fig. 1-11).
Time is the most precious resource, as it cannot be bought, saved, Congruous with the Pareto’s 80/20 principle and Parkinson’s
or stored. Thus, management of time is essential for a productive law, the time management matrix technique channels efforts
and balanced life for those in the organization. The effective use into quadrant II (important but nonurgent) activities. The activi-
of one’s time is best done through a formal time management ties in this quadrant are high yield and include planning, creative
program to improve one’s ability to lead by setting priorities and activity, building relationships, and maintaining productivity.
making choices to achieve goals. The efficient use of one’s time Too often, surgeons spend a majority of their time attending
helps to improve both productivity and quality of life.48-50 to quadrant I (important and urgent) tasks. Quadrant I tasks
It is important for surgeons and surgical trainees to learn include emergencies and unplanned or disorganized situations
and use a formal time-management program. There are ever- that require intensive and often inefficient effort. While most
6 increasing demands placed on surgeons and surgical
trainees to deliver the highest quality care in highly regu-
surgeons and surgical trainees have to deal with emergencies,
they often develop the habit of inappropriately assigning activi-
lated environments. Furthermore, strict regulations on limita- ties into quadrant I; excess time spent on quadrant I tasks leads
tion of work hours demand surgical trainees learn patient care to stress or burnout for the surgeon and distracts from long-term
in a limited amount of time.48-50 All told, these demands are goals. Efficient time management allows surgeons and surgical
enormously stressful and can lead to burnout, drug and/or trainees to be proactive about shifting energy from quadrant I
alcohol abuse, and poor performance.48-50 A time-motion study tasks to quadrant II, emphasizing preplanning and creativity
of general surgery trainees analyzed residents’ self-reported over always attending to the most salient issue at hand, depend-
time logs to determine resident time expenditure on educa- ing on the importance and not the urgency.
tional/service-related activities (Fig. 1-10). 50 Surprisingly, Finally, “the six areas of interest” is an alternative effec-
senior residents were noted to spend 13.5% of their time on tive time management model that can help surgeons and surgi-
low-service, low-educational value activities. This time, prop- cal trainees achieve their goals, live a better-balanced lifestyle,
erly managed, could be used to either reduce work hours or and improve the quality of their lives.49 The process begins by
improve educational efficiency in the context of new work performing a time-motion study in which the activities of 6-hour
hour restrictions. It is therefore critical that time be used increments of time over a routine week are chronicled. At the
wisely on effectively achieving one’s goals. end of the week, the list of activities is analyzed to determine
Parkinson’s law, proposed in 1955 by the U.K. politi- how the 168 hours in 1 week have been spent. The surgical
cal analyst and historian Cyril Northcote Parkinson, states trainee then selects six broad categories of areas of interest
that work expands to fill the time available for its completion,
thus leading individuals to spend the majority of their time on
insignificant tasks.51 Pareto’s 80/20 principle states that 80% of
Time Management Matrix
goals are achieved by 20% of effort and that achieving the final
20% requires 80% of their effort. Therefore, proper planning
for undertaking any goal needs to include an analysis of how Important Quadrant I Quadrant II
much effort will be needed to complete the task.49 Formal time
management programs help surgeons and surgical trainees bet- Nonimportant Quadrant III Quadrant IV
ter understand how their time is spent, enabling them to increase
Urgent Nonurgent
productivity and achieve a better-balanced lifestyle.
Various time allocation techniques have been described.49 Figure 1-11. Time management. (Data from Covey S. The Seven
A frequently used basic technique is the “prioritized list,” also Habits of Highly Effective People. New York, NY: Simon &
known as the ABC technique. Individuals list and assign relative Schuster; 1989.)
(i.e., family, clinical care, education, health, community service, surgeon-leader must build a team where talented individuals are 11
hobbies) and sets a single activity goal in each category every placed in the right job for their skills. The essence of a leader is
day and monitors whether those goals are achieved. This tech- one who enables others to succeed. Team work is imperative to
nique is straightforward and improves one’s quality of life by change, and trust is the make-or-break component. Simply put,
CHAPTER 1
setting and achieving a balanced set of goals of personal inter- teams that trust each other work well, and teams that do not trust
est, while eliminating time-wasting activities. each other do not work well.9
A formal time management program is essential for
modern leadership. The practice and use of time management Creating a Culture of Empathy, Patient-
strategies can help surgeons and surgical trainees achieve and Family-Centered Care, and Personalized
maintain their goals of excellent clinical care for their patients, Surgery
while maintaining a more balanced lifestyle. Creating the right culture is the most challenging of all the sur-
geon-leader’s tasks. Modern surgical departments should focus
Self-Care and Wellness on creating a culture of empathy, patient–family-centered care,
The challenges of practicing medicine place unique stresses on
and personalized surgery. Instilling a positive culture requires
surgeons. A departmental program for improving wellness and
both discipline and consistency because it may take consider-
teaching self-care can help alleviate these stresses. Acknowl-
able time to change how people think, feel, and behave.9,55,56
edging these stresses is an important step for any leader to help
Organizational culture is built around the leader’s vision and
peers at risk. Quality of life surveys have identified individual
values. Coming up with strong values requires genuine com-
protective factors that can be implemented prophylactically.
mitment. A leader should realize that staying true to his or her
These factors for improving self-care and wellness include regu-
values can be challenging when conflicts arise.57
lar exercise programs, maintenance of routine medical care, and
health screening. The following may not apply to all physicians;
however, religious practices, reflective writing, and maximizing WHY WE LEAD
work-life balance have also been demonstrated to be protective.52
Surgeons and physicians overall experience increased rates Choosing to Become a Leader
of suicide, depression, substance abuse, marital and family prob- There are many benefits to becoming a leader. Humankind has
lems, and other stress-related health effects as compared to the pondered the question of whether leaders are born or made for
general population. Suicide rates in physicians are higher among millennia. The best evidence to date indicates that leaders are
those who are divorced, widowed, or never married. Depression both born and made. Leadership potential is a skill that all per-
is a common challenge, with rates as high as 30% among trainees, sons are born with, to some degree, and that can be formally
and higher when lifetime risk is considered. Drug and alcohol trained, learned through observation, and honed with practice.13
abuse among physicians mirrors the general population; however, The positive effects of a leader on others are innumerable,
physicians have higher rates of prescription drug abuse. The abil- including a leader’s positive influence on innovation, diversity,
ity to self-medicate likely contributes to prescription drug abuse culture, and quality. For modern surgeons, leadership skills are
by physicians. Divorce and marriage unhappiness among physi- essential for the delivery of quality patient care; therefore, it is
cians has been attributed to the “psychology of postponement,” the duty of the surgeon to study leadership.
compulsive personality traits that are reinforced and selected for For the surgeon studying to be a better leader, effective
during medical training, and lack of work-life balance. Residents, leadership also has many individual benefits, including rec-
due to their inexperience, may be at higher risk than practicing ognition from one’s peers, promotion, and autonomy. Mod-
physicians. For physicians who do not seek professional help, fear ern leaders are increasingly required to be humble about their
of losing their medical license is the most commonly provided accomplishments in order to be successful and effective. 8
reason. Departmental wellness programs may provide an alterna- Beyond recognition, promotion, and autonomy there are more
tive source of support for these surgeons.52-54 selfless reasons for surgeons to desire leadership. Leadership
The past 10 years have seen a significant increase in atten- is a tool to help make a difference. Leadership is a good path
tion to the issue of physician wellness. Physician wellness has towards a career as an educator, which offers the leader a sense
become an issue transcending specialties and resulting in signif- of accomplishment and satisfaction in seeing others succeed.
icant research. The creation of wellness and self-care programs Some choose to become leaders out of a sense of selfless ser-
within departments represents an opportunity for surgeons to vice, taking on leadership for the benefit of others, or out of a
demonstrate leadership qualities.52-54 desire to solve problems. Leadership may come with material
rewards, including wealth and power, which motivate some.
Recruitment Whatever the motivation, surgeons, in their role as lead-
The challenges of modern medicine and ever-larger medical ers of patient care teams, have a duty to develop some skill in
centers have created a reality where no single surgeon-leader leadership. It would be best for individuals, departments, and
can exercise complete control—it takes a team of leaders with patients if all surgeons sought to develop leadership skills and
shared vision, mission, and goals. To this end, the previously experience in some area of administration, patient care, educa-
discussed “level 5 leader” who embodies personal humility and tion, or research. The benefits to the individual are numerous.
professional will is essential.8 Previous generations whose lead-
ers and departments were composed of self-proclaimed giants Leadership’s Effect on Healthcare Cost and
dominated and suppressed alternative points of view, com- Clinical Outcomes
munication, and innovation. In recent years, there has been a Much attention has rightly been paid to historical leaders’
change to building teams with authentic leaders who have high impact on humanity. Surgical leaders of the past have made
ethical standards and well-developed nontechnical skills, who great contributions on which we may build. All surgeons have
lead by example, and who never compromise excellence. The a responsibility to be leaders, whether at the team level or in
12 an administrative or organizational capacity. To that end, it is benchmarks, such as hospital-acquired infections, which affect
worth noting the benefits of formal leadership education. reimbursement, can be reduced or eliminated depending on the
Large observational studies using trained observers measure.68,69 Medical errors may be reduced, and significant
assessed the effects of different surgical leadership styles on medical errors may have their effects mitigated. Patient satis-
operative cases. Team cohesion and collective efficiency were faction may be improved. The overall financial performance of
PART I
reduced when leaders utilized abusive supervision or over- the institution can be affected in a positive manner.69,70
controlling methods. Abusive supervision alone was associated There are positive correlations between mutual respect,
with decreased “psychological safety.”58 Surgeons perceived clinical leadership, and surgical safety. Traditional command
as having positive leadership characteristics by their staff have and control style leadership negatively impacts psychological
lower 30-day all-cause mortality.59 This is likely due to creating safety resulting in the development of more modern leadership
a culture of safety where the staff can speak up if they notice an styles. The best clinical processes have the potential to break
error and feel they have the latitude to do what is best for the down when there is a toxic work environment and lack of psy-
patient quickly and autonomously.59,60 chological safety within the team.
With increased recognition and attention on human error,
nontechnical skills, including leadership, play a role in patient
The Importance of Diversity and Leadership
The past quarter century has seen a steady increase in diversity
safety. The landmark study, “To Err Is Human,” estimated that
within the field of surgery. Women, as of 2015, represent 38%
almost 100,000 people die each year due to medical errors.20 In
of surgical trainees and 10% of academic professors currently,
the surgical setting, 40% to 50% of errors may be attributed to
but have doubled their representation in the past 20 years.71
communication breakdown. The Multifactor Leadership Ques-
Some fields, such as head and neck surgery and plastic surgery72
tionnaire scores subjects on their demonstration of transforma-
have studied their own subspecialty groups with similar find-
tional leadership behaviors. Transformational leaders exhibit
ings. African Americans comprise both 6% of medical school
the qualities of charisma, inspired motivation, intellectual
graduates, 6% surgical trainees, and 2% to 4% of professors
stimulation, and individualized consideration. In video analysis
of surgery nationwide.73 Hispanics represent 5% of graduat-
of complex surgical operations, surgeons scoring even a single
ing medical students, 9% of general surgery trainees, and 4%
point higher on the transformational leadership score exhibited
to 5% of persons at all levels of academic surgery.73 Physician
3 times more information sharing behaviors, 5 times more posi-
diversity is crucial and may help to address disparities in social
tive voice behaviors, and 10 times more supportive behaviors,
determinants of health.74
all while displaying poor behaviors 12.5 times less frequently
Studies indicate that the bottleneck in diversity occurs at
than their peers.60 Exhibiting the characteristics of transforma-
the level of the medical school application pool, which in turn is
tional leadership clearly has much to offer the surgeon-leader in
caused by educational deficiencies at the primary, secondary, and
preventing serious errors.58-60
collegiate level.73,75-78 As an attempted solution, the University of
The field of trauma contains the largest body of formal
Michigan developed a “pipeline” program that pairs grade-school
study demonstrating the positive effects of leadership on clini-
and high-school students with physicians for experiential learn-
cal results. Strong leadership skills improve both the speed of
ing and the development of mentoring, presentation skills, and
resuscitation and completion of the initial trauma evaluation.61-63
networking.75 It is important for departments of surgery to develop
There is no one optimal style of leadership covering all situa-
a diversity program for recruitment of residents and faculty.
tions; some call for a more empowering leadership style while
Multi-institutional blinded studies indicate that the implementa-
others call for a more directive style. The optimal style of lead-
tion of formal leadership and diversity training improves diversity
ership varies based on team composition, with less experienced
leadership and strategic human resource management.74,78
teams better responding to the directive style, while more expe-
rienced teams work faster with trust and an empowering style.
The formally educated surgical leader should be able to switch LEADERSHIP STYLES
easily between styles based on the situation at hand.56,58,60-64 The principles of leadership can be practiced in a variety of
Leadership styles affect responses to patient safety con- styles. Just as there are many definitions of leadership, many
cerns and protect the organization as a whole. The surgical classifications of styles exist as well. A landmark study by
leader adopts a supervisory capacity while creating a culture of Daniel Goleman in Harvard Business Review identified six
safety. In detail, frontline staff must be encouraged to partici- distinct leadership styles, based on different components of
pate in safety improvement. Staff ownership of safety must be emotional intelligence.79 Emotional intelligence is the ability to
established and upheld. In order to assure this outcome, whistle- recognize, understand, and control the emotions in others and
blowers must be protected. A culture of psychological safety, ourselves. By learning different styles, surgeons and trainees
organizational fairness, and continuous learning is required. can recognize their own leadership style and the effect on the
Subordinates require appropriate authority, autonomy, and lati- team dynamic. Furthermore, it teaches when the situation may
tude to do their jobs and care for patients.60 demand change in style for the best outcome. The six leadership
Formal leadership training has been well studied within styles identified are coercive, authoritative, affiliative, demo-
the Veteran’s Health Administration system using the Surgical cratic, pacesetting, and coaching.
Care Improvement Program. The Medical Team Training Pro- The coercive leader demands immediate compliance. This
gram, for instance, has been shown to result in a 18% decrease style reflects the command and control style that has histori-
in 30-day mortality65 and a 17% decrease in 30-day morbidity.66 cally dominated surgery. Excessive coercive leadership erodes
Also at the organizational level, leaders using an team members’ sense of responsibility, motivation, sense of
empowering style may improve process of care protocols and participation in a shared vision, and ultimately, performance.
increase efficiency. Operating room turnover times specifically The phrase, “Do what I tell you!” brings to mind the coercive
have been shown to be reducible.67 Value-based purchasing leader. However, it is effective in times of crisis to deliver clear,
concise instruction. This style should be used sparingly and is FORMAL LEADERSHIP TRAINING 13
best suited for emergencies. PROGRAMS IN SURGERY
The authoritative leader embodies the phrase “Come
with me,” focusing on mobilizing the team toward a common, History of Leadership Training and the
CHAPTER 1
grand vision. This type of leader allows the team freedom to Multifactor Leadership Questionnaire
innovate, experiment, and devise its own means. Goleman’s Since it has been shown that effective leadership can improve
research indicates this style is often the most effective. These patient outcomes, leadership principles and skills should be taught
leaders display self-confidence, empathy, and proficiency in to surgical trainees using formal leadership training programs.
initiating new ideas and leading people in a new direction. This The importance of teaching leadership skills is reflected by the
is best used when a shift in paradigm is needed. ACGME mandated core competencies (see Table 1-1). However,
The affiliative leader creates harmony and builds emo- surgical trainees, most notably chief residents, find themselves in
tional bonds. This requires employment of empathy, building various leadership roles without ever having experienced formal-
relationships, and emphasis on communication. An affiliative ized leadership training, which has been shown to result in a self-
leader frequently gives positive feedback. This style can allow perceived lack of leadership ability.2 When surveyed on 18 core
poor performance to go uncorrected if too little constructive/ leadership skills (Table 1-3), 92% of residents rated all 18 skills
critical advice is given. Affiliative leadership is most useful as important, but over half rated themselves as “minimally” or
when motivating people during stressful circumstances or heal- “not competent” in 10 out of 18 skills.2 Increasingly, residents and
ing rifts in a team. junior faculty are requesting leadership training and wish to close
The coaching style of leadership focuses on developing the gap between perceived need for training and the implementa-
people for the future. Coaching is leadership through mentor- tion of formal leadership training programs.80-86
ship. The coach gives team members challenging tasks, coun- A number of leadership workshops have been created.
sels, encourages, and delegates. Unlike the affiliative leader Extracurricular leadership programs have been designed mostly
who focuses on positive feedback, the coach helps people iden-
tify their weaknesses and improve their performance, and ties
their work into their long-term career aspirations. This leader-
Table 1-3
ship style builds team capabilities by helping motivated learners
improve. However, this style does not work well when team Eighteen leadership training modules
members are defiant and unwilling to change or learn, or if the
leader lacks proficiency. IMPORTANCE COMPETENCE
The democratic leader forges consensus through participa- SKILLS MEAN SCORE MEAN SCORE*
tion. This leadership style listens to and values each member’s Academic program 3.2 2.4*
input. It is not the best choice in an emergency situation, when development
time is limited, or when teammates cannot contribute informed Leadership training 3.8 2.3*
guidance to the leader. It can also be exasperating if a clear
vision does not arise from the collaborative process. This style is Leadership theory 3.2 2.1*
most appropriate when it is important to obtain team consensus, Effective communication 3.7 2.7*
quell conflict, or create harmony. Conflict resolution 3.8 3*
The pacesetter leader sets high standards for performance
Management principles 3.7 2.7*
and exemplifies them. These leaders identify poor performers
and demand more from them. However, unlike the coach, the Negotiation 3.7 2.8*
pacesetter does not build the skills of those who are not keep- Time management 4 2.8*
ing up. Rather, a pacesetter will either take over the task him- Private or academic practice, 3.6 2*
self or delegate the task to another team member. This style managed care
can be summed up best by the phrase, “Do as I do, now.” This
Investment principles 3.5 2.2*
leadership style works well when it is important to obtain high-
quality results and there is a motivated, capable team. However, Ethics 3.6 3.2
pacesetters can easily become micromanagers who have diffi- Billing, coding, and 3.5 1.7*
culty delegating tasks to team members, which leads to burn out compliance
on the part of the leader. Additionally, team members can feel Program improvement 3 2*
overwhelmed and demoralized by the demands for excellence
Writing proposals 3.3 2.2*
without an empathic counter balance.
Each of the above styles of leadership has strengths and Writing reports 3.4 2.4*
weakness. Importantly, leaders who are the most successful do Public speaking 3.7 2.7*
7 not rely only on one leadership style alone. They use sev-
eral of them seamlessly depending on the situation and the
Effective presentations 3.7 2.7*
Risk management 3.5 2.1*
team members at hand. Therefore, the more styles a leader has
mastered, the better, with particular emphasis on the authorita- Total 3.6 2.5*
tive, affiliative, democratic, and coaching styles. Each leader- *
P <0.001 by Student t-test between mean importance and mean
ship style is a tool that is ultimately employed to guide a team competence scores.
to realizing a vision or goal. Thus, leadership training programs Reproduced with permission from Itani KMF, Liscum K, Brunicardi FC:
should teach the proper use of all leadership styles while adher- Physician leadership is a new mandate in surgical training, Am J Surg.
2004 Mar;187(3):328-331.
ing to the principles of leadership.
14 for physicians with an MBA or management background but Formal leadership training is not restricted to faculty
have not been incorporated into the core residency training alone. Leadership training should begin early and continue
program.80 Also, there are many institutions that have published throughout residency. Surgical residents’ leadership styles have
experiences with leadership retreats or seminars for residents been studied in environments where they are given an assistant
or young physicians.81-84 The ACGME hosts multiple leader- to supervise, as if they were an attending. Most residents were
PART I
ship skills workshops for chief residents, mostly targeted toward able to adapt to difficult operative challenges, in this setting, by
pediatricians, family practitioners, and psychiatrists.85 Similarly, providing a more directed style of leadership to their assistants.
the American College of Surgeons leads an annual 3-day lead- When faced with a less challenging task, or when the surgery
ership conference focusing on leadership attributes, consensus resident’s confidence was particularly high, their leadership
development, team building, conflict resolution, and translation score was also high. For the surgical resident preparing to move
of leadership principles into clinical practice.86-87 These pro- on to the attending level, such skills are necessary to develop.92
grams were all received well by participants and represent a Nontechnical surgical skills, such as leadership, demon-
call for a formal leadership program for all surgical trainees. strate a number of desired effects for the operative team. Patient
An innovative leadership curriculum first implemented in safety, including all cause 30-day mortality, is improved by
2000, prior to work-hour restrictions, taught general surgery stronger nontechnical skills.59 Development of clear and effec-
trainees’ collaborative leadership skills at a time when the tradi- tive communication, situational awareness, team skills, and
tional command-and-control leadership style predominated.2,89,90 decision-making all are correlated with reduced surgical errors.
Surgical residents participated in 18-hour-long modules based Interruptions, such as needing to answer a page during an opera-
on the leadership principles and skills listed in Table 1-2, taught tion, are the only nontechnical factors in surgical error that are
by the surgical faculty. A number of leadership techniques, not directly attributable to leadership style.93
including time management techniques and applied conflict Surgical leaders have a responsibility to make ethical deci-
resolution techniques described earlier, were designed and sions. At this time, there is no standard curriculum to formally
implemented as part of this leadership training program. Within train surgical residents in ethics, despite interest from a majority
6 months of implementation, residents’ self-perceived total of residency program directors.94-97 Several solutions have been
commitment to the highest personal and professional standards, proposed. A case-based approach to ethics training appears to
communication skills, visualization of clear missions of patient have some merit, where monthly hour long ethical dilemmas are
care, and leadership of others toward that mission increased sig- discussed in an informal, nonhierarchical setting.98 In another
nificantly.2,89,90 Remarkably, the positive impact of this leader- study, an ICU-based simulation model demonstrated promise
ship curriculum was significant when measured using tools, for teaching compassion and end-of-life ethics to surgical resi-
such as the Multifactor Leadership Questionnaire (MLQ), social dents. In this model, surgery residents have their first end-of-life
skills inventory, personality inventory, and internal strength conversations with standardized patients simulating the surgical
scorecard.2,89,90 The MLQ is a well-validated instrument that ICU environment.99,100
objectively quantifies leadership beliefs and self-perceived out-
comes across medical and nonmedical disciplines. Based on the Practicing Leadership Skills and Assessing
MLQ, surgical residents more often use a passive-avoidance Leadership Formally With Objective Structured
style of leadership that emphasizes taking corrective action only Clinical Examination (OSCE) and Simulation
after a problem is “significant and obvious.” This tool can also The past decade has seen a demonstrable increase in our knowl-
be used to track progress toward more effective, collaborative edge of how to develop leadership skills, particularly through
styles of leadership. These studies demonstrated the ability to simulation, as well as leadership evaluation through OSCE and
measure leadership behavior of surgical trainees in a standard- other tools. Multiple groups have assessed multidisciplinary
ized, quantifiable format.2,89,90 Taken together, these studies sup- teams, typically composed of nurses, anesthesia groups, and
surgeons for the leadership associated nontechnical skills of
8 port the concept that leadership skills can and should be
taught to surgical trainees, and there are validated tools to communication, teamwork, and situational awareness. Through
measure outcomes. increasingly validated instruments and assessment tools, these
nontechnical skills have been found to be trainable.101 The
Designing the Program OSCE has been established as the gold standard102 for the train-
Success in designing a formal leadership development program ing and assessment of a wide range of clinical and nontechnical
can be achieved through the following method. First, select the skills with high reliability and validity.103-106
right participants at the right time in their career. Junior sur- The OSCE was developed by Harden, at the Ninewells
geons new to practice are ideal; however, they should be given a Hospital in Dundee, Scotland, and first published in 1975.107
chance to get their clinical and research interests off the ground He subsequently coined the term “OSCE” in his 1979 publica-
before they are asked to lead others. Candidates, should be open tion “Assessment of Clinical Competence Using an Objective
to taking on leadership roles and have the right combination of Structured Clinical Examination (OSCE).”108 The purpose of
introspection and humility that lends to professional develop- the OSCE was to address the lack of a reliable method to evalu-
ment. High-quality speakers from the business, legal, creative, ate the clinical abilities of physicians and featured a compre-
and medical worlds should be brought as guest speakers. Topics hensive assessment of history-taking and physical examination
could include leadership overall, strategy, finance, management skills. Early versions also assessed nontechnical skills, patient
skills, feedback, and coaching. Constructive criticism is essential interaction, and professionalism. Since its inception, the OSCE
because prospective leaders will need guidance and mentoring. has matured, been subjected to rigorous tests of reliability and
Surgeons who have been through a formal leadership training validity, and has seen widespread adoption.109-111
program will become proficient at team-building skills and man- OSCEs remain a critical portion of resident evaluation.
agement and will become self-empowered individuals.91 They have been well validated for teaching leadership skills in
trauma and interacting with simulated patients in difficult sce- 1 15
narios. OSCEs can be tailored to a variety of circumstances, Technical stations
including practicing breaking bad news or discussing end of life Clinical stations
0.5
care, dealing with angry or aggressive patients, and simulating
CHAPTER 1
disagreements with other providers or family members.109-112
z score
The potential for OSCEs to train, test, and perfect nontechnical 0
skills, such as leadership, is extraordinary.
A pilot project for the Medical Council of Canada was –0.5
conducted by the University of Toronto and published in 1988
describing the use of an OSCE for evaluating the clinical skills
–1
of international medical graduates applying to Canadian resi- 1 2 3 4 5
dency.113 Effective communication and language proficiency PGY Level
have been key components since the beginning. A compre-
Figure 1-12. Resident assessment by year of training by OSCE.
hensive review of this program 2 years later confirmed the
Technical skills assessment demonstrates a rapid and continual pro-
reliability and validity of using an OSCE for this purpose.114
gression through 5 years of training, whereas clinical evaluations
The Medical Council of Canada has subsequently mandated a show only modest improvement over the same time period. (Data
requirement for an OSCE evaluation of all international gradu- from Turner JL, Dankoski ME. Objective structured clinical exams:
ates applying for positions in Canada. In place for the past two a critical review, Fam Med. 2008 Sep;40(8):574-578.)
decades, the program has ensured a baseline proficiency of skill,
attitude, knowledge, and other nontechnical skills.115
OSCEs quickly gained acceptance as an established tool The past 2 to 3 years has seen an explosion in simula-
to assess learners in a comprehensive manner and became the tion technology and research. In one particularly strong study,
inspiration for the creation of the USMLE Step 2 Clinical Skills multiple teams were assessed for hemorrhage and airway emer-
(CS) examination, required for all U.S. medical students prior to gencies. The Non-Technical Skills for Surgeons (NOTSS) tool
licensure.116 Indeed, medical students whose schools use OSCE was used to assess teams prior to and during simulation. For
as practice do better on USMLE Step 2.117 The USMLE Step 2 surgeons, higher NOTSS scores were associated with a quicker
CS examination meets the criteria, discussed in the following resolution of the simulation crisis.125 Advances are being made
section, for a thorough and well-designed OSCE examination, in using simulation to solve difficult to teach physical examina-
due to its 12-station design which takes 8 hours to complete. It tion skills such as breast lump detection and prostate or rectal
has been found to be a valid and comprehensive evaluation of cancers.126,127 Studies assessing these new simulation tools have
a student’s clinical abilities, admittedly at massive expense to also indicated that many attending level surgeons would benefit
medical students.118 In the United States, osteopathic medical from continued simulation practice both for keeping operative
students take the OSCE-style Level 2 Performance Evaluation.119 skills fresh and preventing the decline of physical exam skills,
Although station number and total duration are not com- for instance during dedicated research time.126-128
pletely agreed upon, data indicate that the OSCE examination The Objective Structured Assessment of Technical Skills
should be between 3 and 6 hours and 8 to 10 stations in length (OSATS) was initially developed as a bench station examination.
in order to obtain reliable (r = ≥0.7) communication, history, It was later applied to intraoperative skill assessment, and appears
and physical examination skills. A guideline was that at least to be an additional option for programs seeking a validated and
seven cases are needed in any domain to achieve reliability. The reliable method for mixing technical skills assessment into simu-
testing period may be spread over several sessions making up lations of nontechnical exercises to create a more “real world”
an aggregate score in order to maintain validity. Many medical simulation.129-133 With recent focus on milestones and proficiency-
schools prepare their students for clinical practice with OSCE- based promotion, as compared to time-based promotion of resi-
style examinations throughout the year, which, taken together, dents, there is a need to reliably assess intraoperative skill.134
are summative of a high-quality, multistation, valid OSCE. Digitization and modern computing have created new opportu-
Checklists are typically the standard scoring tools; however, nities for simulation and education. One proposed method is a
checklists alone may not be as reliable as a more comprehen- real-time, mobile web system featuring consistent and accurate
sive review by more experienced clinicians—particularly when assessment of the residents’ performance. The platform enabled
assessing more advanced students and residents.120 All of the timely recording of data, was efficient in terms of how much fac-
licensure examinations, discussed previously, meet the criteria ulty time it took to complete an assessment (average 2 minutes),
for a well-designed OSCE based on number of stations and time and from a validity standpoint did trend well overall with resident
duration. postgraduate year. The system itself fulfilled the ACGME and
Beginning in 2003, the ACGME mandated the use of American Board of Surgery mandate for program assessment of
OSCEs within residency programs. At the time, residents were resident performance in the operating room.134
wary of its adoption, particularly fearing its use as a tool for Nontechnical skills often erode during stressful events,
determining promotion. Residents’ perceptions of the examina- particularly in surgery where bleeding, complexity of the opera-
tion, over time, did change to reflect an acceptance of its use for tion, time-constraints, and equipment problems can have a nega-
grading both technical and nontechnical skills.121-123 tive effect. Additionally, roadblocks with insurance and other
In the United States, the OSCE assesses technical and third parties, critical illness, and delivering bad news add differ-
nontechnical skills in an accurate and valid fashion. The OSCE ent kinds of stress.135 Indeed, video analysis of real operations
demonstrates a rapid progression of technical skills highly cor- indicates that attending surgeons typically take over, change
related to a postgraduate year, whereas clinical skills improve their style of leadership, and decrease their teaching in the oper-
at a more moderate rate121 (Fig. 1-12). ating room once unintended events occur.136
16 By using simulated patients, patient-centered models, and duties decrease the amount of time they can spend in the
intensive and immersive training, nontechnical skills including operating room. Simulation represents the future of medicine
communication can improve interview techniques.137,138 Post com- and an excellent opportunity for research and development.
munication skills training at the 12-month follow-up demonstrated Medicine, including surgery, has much ground to make up
that the training was effective, and with real clinical practice after in regards to simulation training compared to other high-risk
PART I
the training communication skills had improved even more.139 fields, such as the military, space, and aeronautics. Modern
Lastly, there appears to be a positive feedback loop tying surgical leaders should recognize surgical simulation as criti-
nontechnical leadership skills with self-perceived operating cal to their organization’s success.
room prowess. Those surgeons who rate their own technical
skills highly are also more likely to engage in positive leader- Evaluation of Surgeon Performance
ship skills, including teaching in the operating room, handle Multiple organizations are evaluating the technical and nontechnical
difficult situations, and provide more clear instructions.140 skills of surgeons in a real-time basis. We have included this com-
Simulation may be particularly critical for preventing techni- prehensive list of organizations (Table 1-4) with a brief description
cal skill decline in residents on dedicated research time or for of their purpose and mechanisms of evaluation. Several of these
attending surgeons whose research, clinic, or administrative involve technical skills evaluations and most involve nontechnical
Table 1-4
Multiple organizations have been created to evaluate both the technical and nontechnical skills of surgeons141
EVALUATION EVALUATION OF
MAIN SKILLS, CONDITIONS, OR OF TECHNICAL NONTECHNICAL
ORGANIZATION NAME DESCRIPTION QUALITIES EVALUATED SKILLS? SKILLS?
Hospital Consumer A public reporting initiative that Communication with nurses, No Yes
Assessment measures patient perspectives communication with doctors,
of Healthcare on and satisfaction with responsiveness of hospital
Providers and hospital care based on qualities staff, pain management,
Systems (HCAHPS) of healthcare that patients view communication about
as important. medicines, discharge
information, care transition
Clinical and Group A public reporting initiative that Access to care, provider No Yes
Consumer measures patient perspectives communication, test results,
Assessment on and satisfaction with care office staff, overall provider
of Healthcare provided in an office setting rating
Providers based on qualities of healthcare
and Systems that patients view as important.
(CGCAHPS)
Datix, Incident A database of incidents that System issues, patient safety Yes Yes
Reporting improves reliability of and quality issues, provider
physicians by improving behavior, leadership style
rates of reporting, promoting
ownership of mistakes, and
improving patient safety.
Patient Advocacy A system that compiles patient Unprofessional behavior deemed No Yes
Reporting System complaints into a complaint as disrespectful and rude
(PARS) index for each physician for
comparison with other medical
group members and to help
identify high-malpractice-risk
physicians who may benefit
from peer intervention.
Co-worker A system in which physicians Unprofessional behavior deemed Yes Yes
Observation document coworker as disrespectful and unsafe
Reporting System unprofessional conduct in order
to provide nonjudgmental
and timely feedback and to
encourage self-reflection and
change.
(Continued)
Table 1-4 17
Multiple organizations have been created to evaluate both the technical and nontechnical skills of surgeons141(Continued)
CHAPTER 1
EVALUATION EVALUATION OF
MAIN SKILLS, CONDITIONS, OR OF TECHNICAL NONTECHNICAL
ORGANIZATION NAME DESCRIPTION QUALITIES EVALUATED SKILLS? SKILLS?
American Board of A program that documents a Restrictions on medical license, Yes Yes
Surgery (ABS) surgeon’s ongoing commitment restrictions on hospital
Maintenance of to professionalism, lifelong privileges, continuing medical
Certification (MOC) learning, and practice education, self-assessment of
Program improvement through continuing medical education,
self-report. cognitive expertise, ongoing
participation in quality
assessment program relevant to
the surgeon’s practice
Hospital Compare A database that is part of the Hospital Compare is based on No Yes
Centers for Medicare & data from HCAHPS and
Medicaid Services (CMS) evaluates hospitals by the same
Hospital Quality Initiative guidelines as HCAHPS
and provides information
on hospital performance
and quality of care based on
consumer perspectives so
that patients can assess and
compare hospitals.
Federation of State An organization representing all Medical knowledge, patient Yes Yes
Medical Boards state medial and osteopathic complaints, violations of the
(FSMB) boards in the United States that law
license physicians and sponsors
the United States Medical
Licensing Examination.
Internet clinical scores A database of direct patient Professionalism, communication, No Yes
opinions of physicians, timeliness
provided through various
sources, including
Healthgrades.com, RateMDs.
com, and Yelp.
Hospital-Acquired A government program that Foreign objects retained after Yes No
Condition Reduction provides incentives for hospitals surgery, air embolism,
Program to reduce the number of blood incompatibility,
undesirable patient conditions pressure ulcers, falls, poor
resulting from their stay in the glycemic control, catheter-
hospital and that could have associate infections, surgical
been avoided by adjusting site infections, deep vein
hospital reimbursement rates thrombosis, pulmonary
accordingly. embolism, pneumothorax
American College of A program that collects Surgical complications rates, Yes No
Surgeons National information on and provides surgical site infections, urinary
Surgical Quality a risk-adjusted ranking tract infections, readmission
Improvement of preventable surgical rates, surgical outcomes
Program (ACS complication rates to
NSQIP) encourage providers to
improve care.
Centers for Medicare A collaborative healthcare Rates of infection, cardiac, Yes No
& Medicaid organization that collects venous thromboembolism,
Services Surgical data on surgical complication vascular, and respiratory,
Care Improvement rates based on established complications of surgery
Project (CMS SCIP) guidelines.
18 skills. Additionally, most have been tied to performance evalua- of student, postdoctoral fellow, or junior collaborator.144 In
tions and even salary and discipline up to and including loss of academic medicine, evidence-based studies have shown benefits
licensure. To our knowledge, this is the first comprehensive listing to the mentees that include enhanced research productivity, higher
of the various agencies that evaluate surgeon performance.141 likelihood of obtaining research grants, and greater success
in obtaining desired positions in practice or at academic
PART I
MENTORING AND DEVELOPMENT institutions.145 Mentoring provides benefits to the mentors

themselves, including refinement of their own personal leadership
Mentoring skills and a strong sense of satisfaction and accomplishment.
A formal leadership training program for surgical trainees Mentorship is essential to accomplish the successful
should include mentoring. Mentoring is the active process by development of surgical trainees and to help cultivate their
which an experienced, empathetic person guides another indi- vision. Therefore, formal leadership training programs that have
vidual in the development and self-recognition of their own a goal of training the future leaders in surgery should include
vision, learning, core competencies, and professional develop- mentoring.
ment. Halstead established the concept of a surgical mentor who
directly provided the trainees with professional and technical Modeling Leadership for Medical Students and
guidance. Halstead’s concept went beyond a simple preceptor- the “Hidden Curriculum”
ship by emphasizing clinical decision making based on scien- Medical students enter school with great empathy, excitement,
tific evidence. His goal was to develop surgeons who would go optimism, and an idealistic vision. They have self-selected to enter
on to become outstanding leaders and innovators in the field. a profession of healing and achieved entry into a highly coveted
Although surgery has changed dramatically since Halstead’s graduate training program with centuries of tradition. Yet, these
era, mentorship remains crucial in surgical training. In addition medical students are naive to the actual practice of medicine and
to teaching technical skills, clinical judgment, and scientific its professional norms. Along the way to becoming a doctor, many
inquiry, modern-day mentors must also model effective com- medical students lose some of the optimism, empathy, and excite-
munication, empathy, humanism, and the prioritization of comment, particularly during their first and third years of school. Some
peting professional and personal activities. students come to see the patient-physician relationship as an after-
The mentor must also be an experienced and trusted advi- thought to providing care.145,146 Through the “hidden curriculum,”
sor committed to the success of the mentee. A greater level of formal leadership training, and modeling of professional behavior,
trust and commitment distinguishes the mentor from the teacher. surgical residents, and attendings can help medical students to real-
More than a teacher, a mentor is a coach. The goal of a teacher ize their vision of becoming empathic physicians.
is to pass on a defined level of knowledge for each stage of a Traditionally, medical schools and professors have
student’s education. The underlying premise is a limited level unknowingly relied on a hidden curriculum to mold these ide-
of advancement for the student. The coach, on the other hand, alistic students into capable professionals. The hidden curricu-
has the sole purpose to make his or her student the best at their lum is the informal social norms learned by students implicitly,
game, with an unlimited level of advancement. Modern men- based on their observations of resident and attending behavior.
torship implies a partnership between the mentor and the men- The hidden curriculum has always been present in education, for
tee. Surgical residency program chairs and program directors better or worse, and may be unmasked and studied, but cannot
must recruit and develop faculty “coaches” to mentor residents be eliminated. Medical students actively engage in seeking out
to optimize their potential. Emeritus Chair of the University mentors, and naturally and subconsciously look to their men-
of California, Los Angeles Head and Neck Surgery, Dr. Paul tors for cues on how to conduct themselves as physicians, the
Ward, said it best: “We strive to produce graduates of our resi- same way in which a child learns how to behave from a parent or
dency program who are among those who change the way we older sibling. Whether or not the witnessed behavior is a positive
think and practice.”142 Having more than 25 former residents example of professionalism, the student will begin to perceive
become chairs of academic head and neck surgical programs, that behavior as normal and acceptable. For better or worse, the
Dr. Ward embodied the role as a surgeon’s coach. The respon- professional norms of medicine (the Hippocratic oath, respect to
sibilities of an effective mentor are summarized by Barondess: patients and colleagues, ethical conduct, personal accountability,
“Mentoring, to be effective, requires of the mentor empathy, empathy, and altruism) are modeled in every personal encounter.
maturity, self-confidence, resourcefulness, and willingness to It is imperative that all resident and attending surgeons under-
commit time and energy to another. The mentor must be able stand that the medical students are observing them closely. When
to offer guidance for a new and evolving professional life, to resident and attending surgeons model professional behavior, the
stimulate and challenge, to encourage self-realization, to fos- hidden curriculum becomes a useful tool for professional devel-
ter growth, and to make more comprehensible the landscape in opment.147-150 This consistent modeling of professional behavior
which the protégé stands.”143 is one necessary component of leadership.
One of the major goals of mentors is to assess the aptitudes During their clinical years, medical students experience
and abilities of mentees with regard to the appropriateness of their both an exponential growth in knowledge and a measurable
vision for their surgical career. Proper selection of the appropriate decline in empathy towards their patients. Initially, medical stu-
mentor can bring to the mentee much needed wisdom, guidance, dents are filled with excitement and wonder during their first
and resources and can expand the scope of his or her vision. In patient encounters. The rapid pace of clinical work, acquisition
addition, the mentor can refine the leadership skills taught to of knowledge, and intense experiences create stress for the stu-
mentees in formal training programs. Highly successful dent, both positively and negatively. Scrubbing into the operat-
9 surgeons most often have had excellent surgical mentors. It ing room, witnessing the passing of a patient, helping deliver
is impressive to note that more than 50% of United States’ Nobel a baby, and studying for boards are impactful milestones that
laureates have served under other Nobel laureates in the capacity each student experiences in a matter of months. Due to the
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qu’à Tristan, qu’ils peuvent sortir de leurs lits et venir céans.—Tu as
encouru la peine de mort, dit froidement Louis XI au Brabançon, qui
heureusement ne l’entendit pas, tu en as au moins dix sur la
conscience, toi! Là, Louis XI laissa échapper un rire muet, et fit une
pause:—Mais, rassure-toi, reprit-il en remarquant la pâleur étrange
répandue sur le visage de l’avare, tu es meilleur à saigner qu’à tuer!
Et, moyennant quelque bonne grosse amende au profit de mon
épargne, tu te tireras des griffes de ma justice; mais si tu ne fais pas
bâtir au moins une chapelle en l’honneur de la Vierge, tu es en
passe de te bailler des affaires graves et chaudes pendant toute
l’éternité.
—Douze cent trente et quatre-vingt-sept mille écus font treize
cent dix-sept mille écus, répondit machinalement Cornélius, absorbé
dans ses calculs. Treize cent dix-sept mille écus de détournés!
—Il les aura enfouis dans quelque retrait, dit le roi qui
commençait à trouver la somme royalement belle. Voilà l’aimant qui
l’attirait toujours ici. Il sentait son trésor.
Là-dessus Coyctier entra. Voyant l’attitude de Cornélius, il
l’observa savamment pendant que le roi lui racontait l’aventure.
—Sire, répondit le médecin, rien n’est surnaturel en cette affaire.
Notre torçonnier a la propriété de marcher pendant son sommeil.
Voici le troisième exemple que je rencontre de cette singulière
maladie. Si vous vouliez vous donner le plaisir d’être témoin de ses
effets, vous pourriez voir ce vieillard aller sans danger au bord des
toits, à la première nuit où il sera pris par un accès. J’ai remarqué,
dans les deux hommes que j’ai déjà observés, des liaisons
curieuses entre les affections de cette vie nocturne et leurs affaires,
ou leurs occupations du jour.
—Ah! maître Coyctier, tu es savant.
—Ne suis-je pas votre médecin, dit insolemment le physicien.
A cette réponse, Louis XI laissa échapper le geste qu’il lui était
familier de faire lorsqu’il rencontrait une bonne idée, et qui consistait
à rehausser vivement son bonnet.
—Dans cette occurrence, reprit Coyctier en continuant, les gens
font leurs affaires en dormant. Comme celui-ci ne hait pas de
thésauriser, il se sera livré tout doucement à sa plus chère habitude.
Aussi a-t-il dû avoir des accès toutes les fois qu’il a pu concevoir
pendant la journée des craintes pour ses trésors.
—Pasques Dieu! quel trésor, s’écria le roi.
—Où est-il? demanda Cornélius, qui par un singulier privilége de
notre nature, entendait les propos du médecin et du roi, tout en
restant presque engourdi par ses idées et par son malheur.
—Ah! reprit Coyctier avec un gros rire diabolique, les
noctambules n’ont au réveil aucun souvenir de leurs faits et gestes.
—Laissez-nous, dit le roi.
Quand Louis XI fut seul avec son compère, il le regarda en
ricanant à froid.
—Messire Hoogworst, ajouta-t-il en s’inclinant, tous les trésors
enfouis en France sont au roi.
—Oui, sire, tout est à vous, et vous êtes le maître absolu de nos
vies et de nos fortunes; mais jusqu’à présent vous avez eu la
clémence de ne prendre que ce qui vous était nécessaire.
—Écoute, mon compère? Si je t’aide à retrouver ce trésor, tu
peux hardiment et sans crainte en faire le partage avec moi.
—Non, sire, je ne veux pas le partager, mais vous l’offrir tout
entier, après ma mort. Mais quel est votre expédient?
—Je n’aurai qu’à t’épier moi-même pendant que tu feras tes
courses nocturnes. Un autre que moi serait à craindre.
—Ah! sire, reprit Cornélius en se jetant aux pieds de Louis XI,
vous êtes le seul homme du royaume à qui je voudrais me confier
pour cet office, et je saurai bien vous prouver ma reconnaissance
pour la bonté dont vous usez envers votre serviteur, en m’employant
de mes quatre fers au mariage de l’héritière de Bourgogne avec
monseigneur. Voilà un beau trésor, non plus d’écus, mais de
domaines, qui saura rendre votre couronne toute ronde.
—La la, Flamand, tu me trompes, dit le roi en fronçant les
sourcils, ou tu m’as mal servi.
—Comment, sire, pouvez-vous douter de mon dévouement?
vous qui êtes le seul homme que j’aime.
—Paroles que ceci, reprit le roi en envisageant le Brabançon. Tu
ne devais pas attendre cette occasion pour m’être utile. Tu me vends
ta protection, Pasques Dieu! à moi Louis le Onzième. Est-ce toi qui
es le maître, et suis-je donc le serviteur?
—Ah! sire, répliqua le vieux torçonnier, je voulais vous
surprendre agréablement par la nouvelle des intelligences que je
vous ai ménagées avec ceux de Gand; et j’en attendais la
confirmation par l’apprenti d’Oosterlinck. Mais, qu’est-il devenu?
—Assez, dit le roi. Nouvelle faute. Je n’aime pas qu’on se mêle,
malgré moi, de mes affaires. Assez! Je veux réfléchir à tout ceci.
Maître Cornélius retrouva l’agilité de la jeunesse pour courir à la
salle basse, où était sa sœur.
—Ah! Jeanne, ma chère âme, nous avons ici un trésor où j’ai mis
les treize cent mille écus! Et c’est moi! moi! qui suis le voleur.
Jeanne Hoogworst se leva de son escabelle, et se dressa sur
ses pieds, comme si le siége qu’elle quittait eût été de fer rouge.
Cette secousse était si violente pour une vieille fille accoutumée
depuis de longues années à s’exténuer par des jeûnes volontaires,
qu’elle tressaillit de tous ses membres et ressentit une horrible
douleur dans le dos. Elle pâlit par degrés, et sa face, dont il était si
difficile de déchiffrer les altérations parmi les rides, se décomposa
pendant que son frère lui expliquait et la maladie dont il était la
victime, et l’étrange situation dans laquelle ils se trouvaient tous
deux.
—Nous venons, Louis XI et moi, dit-il en finissant, de nous mentir
l’un à l’autre comme deux marchands de myrobolan. Tu comprends,
mon enfant, que, s’il me suivait, il aurait à lui seul le secret du trésor.
Le roi seul au monde peut épier mes courses nocturnes. Je ne sais
si la conscience du roi, tout près qu’il soit de la mort, pourrait résister
à treize cent dix-sept mille écus. Il faut le prévenir, dénicher les
merles, envoyer tous nos trésors à Gand, et toi seule...
Cornélius s’arrêta soudain, en ayant l’air de peser le cœur de ce
souverain, qui rêvait déjà le parricide à vingt-deux ans. Lorsque
l’argentier eut jugé Louis XI, il se leva brusquement, comme un
homme pressé de fuir un danger. A ce mouvement, sa sœur, trop
faible ou trop forte pour une telle crise, tomba roide; elle était morte.
Maître Cornélius saisit sa sœur, la remua violemment, en lui disant:
—Il ne s’agit pas de mourir. Après, tu en auras tout le temps. Oh!
c’est fini. La vieille guenon n’a jamais rien su faire à propos. Il lui
ferma les yeux et la coucha sur le plancher; mais alors il revint à
tous les sentiments nobles et bons qui étaient dans le plus profond
de son âme; et, oubliant à demi son trésor inconnu:—Ma pauvre
compagne, s’écria-t-il douloureusement, je t’ai donc perdue, toi qui
me comprenais si bien! Oh! tu étais un vrai trésor. Le voilà, le trésor.
Avec toi, s’en vont ma tranquillité, mes affections. Si tu avais su quel
profit il y avait à vivre seulement encore deux nuits, tu ne serais pas
morte, uniquement pour me plaire, pauvre petite! Eh! Jeanne, treize
cent dix-sept mille écus! Ah! si cela ne te réveille pas... Non. Elle est
morte!
Là-dessus, il s’assit, ne dit plus rien; mais deux grosses larmes
sortirent de ses yeux et roulèrent dans ses joues creuses; puis, en
laissant échapper plusieurs ha! ha! il ferma la salle et remonta chez
le roi. Louis XI fut frappé par la douleur empreinte dans les traits
mouillés de son vieil ami.
—Qu’est ceci? demanda-t-il.
—Ah! sire, un malheur n’arrive jamais seul. Ma sœur est morte.
Elle me précède là-dessous, dit-il en montrant le plancher par un
geste effrayant.
—Assez! s’écria Louis XI qui n’aimait pas à entendre parler de la
mort.
—Je vous fais mon héritier. Je ne tiens plus à rien. Voilà mes
clefs. Pendez-moi, si c’est votre bon plaisir, prenez tout, fouillez la
maison, elle est pleine d’or. Je vous donne tout...
—Allons, compère, reprit Louis XI, qui fut à demi attendri par le
spectacle de cette étrange peine, nous retrouverons le trésor par
quelque belle nuit, et la vue de tant de richesses te redonnera cœur
à la vie. Je reviendrai cette semaine...
—Quand il vous plaira, sire...
A cette réponse, Louis XI, qui avait fait quelques pas vers la
porte de sa chambre, se retourna brusquement. Alors, ces deux
hommes se regardèrent l’un l’autre avec une expression que ni le
pinceau ni la parole ne peuvent reproduire.
—Adieu, mon compère! dit enfin Louis XI d’une voix brève et en
redressant son bonnet.
—Que Dieu et la Vierge vous conservent leurs bonnes grâces!
répondit humblement le torçonnier en reconduisant le roi.
Après une si longue amitié, ces deux hommes trouvaient entre
eux une barrière élevée par la défiance et par l’argent, lorsqu’ils
s’étaient toujours entendus en fait d’argent et de défiance; mais ils
se connaissaient si bien, ils avaient tous deux une telle habitude l’un
de l’autre, que le roi devait deviner, par l’accent dont Cornélius
prononça l’imprudent—Quand il vous plaira, sire! la répugnance que
sa visite causerait désormais à l’argentier, comme celui-ci reconnut
une déclaration de guerre dans—l’Adieu, mon compère! dit par le
roi. Aussi, Louis XI et son torçonnier se quittèrent-ils bien
embarrassés de la conduite qu’ils devaient tenir l’un envers l’autre.
Le monarque possédait bien le secret du Brabançon; mais celui-ci
pouvait aussi, par ses relations, assurer le succès de la plus belle
conquête que jamais roi de France ait pu faire, celle des domaines
appartenant à la maison de Bourgogne, et qui excitaient alors l’envie
de tous les souverains de l’Europe. Le mariage de la célèbre
Marguerite dépendait des gens de Gand et des Flamands, qui
l’entouraient. L’or et l’influence de Cornélius devaient puissamment
servir les négociations entamées par Desquerdes, le général auquel
Louis XI avait confié le commandement de l’armée campée sur la
frontière de Belgique. Ces deux maîtres renards étaient donc
comme deux duellistes dont les forces auraient été neutralisées par
le hasard. Aussi, soit que depuis cette matinée la santé de Louis XI
eût empiré, soit que Cornélius eût contribué à faire venir en France
Marguerite de Bourgogne, qui arriva effectivement à Amboise, au
mois de juillet de l’année 1483, pour épouser le dauphin, auquel elle
fut fiancée dans la chapelle du château, le roi ne leva point
d’amende sur son argentier, aucune procédure n’eut lieu, mais ils
restèrent l’un et l’autre dans les demi-mesures d’une amitié armée.
Heureusement pour le torçonnier, le bruit se répandit à Tours que sa
sœur était l’auteur des vols, et qu’elle avait été secrètement mise à
mort par Tristan. Autrement, si la véritable histoire y eût été connue,
la ville entière se serait ameutée pour détruire la Malemaison avant
qu’il eût été possible au roi de la défendre. Mais si toutes ces
présomptions historiques ont quelque fondement relativement à
l’inaction dans laquelle resta Louis XI, il n’en fut pas de même chez
maître Cornélius Hoogworst. Le torçonnier passa les premiers jours
qui suivirent cette fatale matinée dans une occupation continuelle.
Semblable aux animaux carnassiers enfermés dans une cage, il
allait et venait, flairant l’or à tous les coins de sa maison, il en
étudiait les crevasses, il en consultait les murs, redemandant son
trésor aux arbres du jardin, aux fondations et aux toits des tourelles,
à la terre et au ciel. Souvent il demeurait pendant des heures
entières debout, jetant ses yeux sur tout à la fois, les plongeant dans
le vide. Sollicitant les miracles de l’extase et la puissance des
sorciers, il tâchait de voir ses richesses à travers les espaces et les
obstacles. Il était constamment perdu dans une pensée accablante,
dévoré par un désir qui lui brûlait les entrailles, mais rongé plus
grièvement encore par les angoisses renaissantes du duel qu’il avait
avec lui-même, depuis que sa passion pour l’or s’était tournée contre
elle-même; espèce de suicide inachevé qui comprenait toutes les
douleurs de la vie et celles de la mort. Jamais le vice ne s’était
mieux étreint lui-même; car l’avare, s’enfermant par imprudence
dans le cachot souterrain où gît son or, a, comme Sardanapale, la
jouissance de mourir au sein de sa fortune. Mais Cornélius, tout à la
fois le voleur et le volé, n’ayant le secret ni de l’un ni de l’autre,
possédait et ne possédait pas ses trésors: torture toute nouvelle,
toute bizarre, mais continuellement terrible. Quelquefois, devenu
presque oublieux, il laissait ouvertes les petites grilles de sa porte, et
alors les passants pouvaient voir cet homme déjà desséché, planté
sur ses deux jambes au milieu de son jardin inculte, y restant dans
une immobilité complète, et jetant à ceux qui l’examinaient un regard
fixe, dont la lueur insupportable les glaçait d’effroi. Si, par hasard, il
allait dans les rues de Tours, vous eussiez dit d’un étranger; il ne
savait jamais où il était, ni s’il faisait soleil ou clair de lune. Souvent il
demandait son chemin aux gens qui passaient, en se croyant à
Gand, et semblait toujours en quête de son bien perdu. L’idée la plus
vivace et la mieux matérialisée de toutes les idées humaines, l’idée
par laquelle l’homme se représente lui-même en créant en dehors
de lui cet être tout fictif, nommé la propriété, ce démon moral lui
enfonçait à chaque instant ses griffes acérées dans le cœur. Puis,
au milieu de ce supplice, la Peur se dressait avec tous les
sentiments qui lui servent de cortége. En effet, deux hommes
avaient son secret, ce secret qu’il ne connaissait pas lui-même.
Louis XI ou Coyctier pouvaient aposter des gens pour surveiller ses
démarches pendant son sommeil, et deviner l’abîme ignoré dans
lequel il avait jeté ses richesses au milieu du sang de tant
d’innocents; car auprès de ses craintes veillait aussi le Remords.
Pour ne pas se laisser enlever, de son vivant, son trésor inconnu, il
prit, pendant les premiers jours qui suivirent son désastre, les
précautions les plus sévères contre son sommeil; puis ses relations
commerciales lui permirent de se procurer les antinarcotiques les
plus puissants. Ses veilles durent être affreuses; il était seul aux
prises avec la nuit, le silence, le remords, la peur, avec toutes les
pensées que l’homme a le mieux personnifiées, instinctivement
peut-être, obéissant ainsi à une vérité morale encore dénuée de
preuves sensibles. Enfin, cet homme si puissant, ce cœur endurci
par la vie politique et la vie commerciale, ce génie obscur dans
l’histoire, dut succomber aux horreurs du supplice qu’il s’était créé.
Tué par quelques pensées plus aiguës que toutes celles auxquelles
il avait résisté jusqu’alors, il se coupa la gorge avec un rasoir. Cette
mort coïncida presque avec celle de Louis XI, en sorte que la
Malemaison fut entièrement pillée par le peuple. Quelques anciens
du pays de Touraine ont prétendu qu’un traitant, nommé Bohier,
trouva le trésor du torçonnier, et s’en servit pour commencer les
constructions de Chenonceaux, château merveilleux qui, malgré les
richesses de plusieurs rois, le goût de Diane de Poitiers et celui de
sa rivale Catherine de Médicis pour les bâtiments, reste encore
inachevé.
Heureusement pour Marie de Sassenages, le sire de Saint-Vallier
mourut, comme on sait, dans son ambassade. Cette maison ne
s’éteignit pas. La comtesse eut, après le départ du comte, un fils
dont la destinée est fameuse dans notre histoire de France, sous le
règne de François Ier. Il fut sauvé par sa fille, la célèbre Diane de
Poitiers, l’arrière-petite-fille illégitime de Louis XI, laquelle devint
l’épouse illégitime, la maîtresse bien-aimée de Henri II; car la
bâtardise et l’amour furent héréditaires dans cette noble famille!
Au château de Saché, novembre et décembre 1831.

SUR CATHERINE DE MÉDICIS.
A MONSIEUR LE MARQUIS DE PASTORET,

Membre de l’Académie des Beaux-Arts.
Quand on songe au nombre étonnant de volumes publiés

pour rechercher le point des Alpes par lequel Annibal opéra
son passage, sans qu’on puisse aujourd’hui savoir si ce fut,
selon Witaker et Rivaz, par Lyon, Genève, le Saint-Bernard et
le val d’Aoste; ou, selon Letronne, Follard, Saint-Simon et
Fortia d’Urban, par l’Isère, Grenoble, Saint-Bonnet, le Mont-
Genèvre, Fenestrelle et le pas de Suze; ou, selon Larauza,
par le Mont-Cenis et Suze; ou, selon Strabon, Polybe et de
Luc, par le Rhône, Vienne, Yenne et le Mont-du-Chat; ou,
selon l’opinion de quelques gens d’esprit, par Gênes, la
Bochetta et la Scrivia, opinion que je partage, et que
Napoléon avait adoptée, sans compter le vinaigre avec lequel
les roches alpestres ont été accommodées par quelques
savants; doit-on s’étonner, monsieur le marquis, de voir
l’histoire moderne si négligée, que les points les plus
importants en soient obscurs et que les calomnies les plus
odieuses pèsent encore sur des noms qui devraient être
révérés? Remarquons, en passant, que le passage d’Annibal
est devenu presque problématique à force d’éclaircissements.
Ainsi le père Ménestrier croit que le Scoras désigné par
Polybe est la Saône; Letronne, Larauza et Schweighauser y
voient l’Isère; Cochard, un savant lyonnais, y voit la Drôme;
pour quiconque a des yeux, il se trouve entre Scoras et
Scrivia de grandes ressemblances géographiques et
linguistiques, sans compter la presque certitude du mouillage
de la flotte carthaginoise à la Spezzia ou dans la rade de
Gênes? Je concevrais ces patientes recherches, si la bataille
de Cannes était mise en doute; mais puisque ses résultats
sont connus, à quoi bon noircir tant de papier par tant de
suppositions qui sont en quelque sorte les arabesques de
l’hypothèse; tandis que l’histoire la plus importante au temps
actuel, celle de la Réformation, est pleine d’obscurités si
fortes qu’on ignore le nom de l’homme[1] qui faisait naviguer
un bateau par la vapeur à Barcelone dans le temps que
Luther et Calvin inventaient l’insurrection de la pensée? Nous
avons, je crois, la même opinion, après avoir fait, chacun de
notre côté, les mêmes recherches sur la grande et belle figure
de Catherine de Médicis. Aussi ai-je pensé que mes études
historiques sur cette reine seraient convenablement
adressées à un écrivain qui depuis si longtemps travaille à
l’histoire de la Réformation, et que je rendrais ainsi au
caractère et à la fidélité de l’homme monarchique, un public
hommage, peut-être précieux par sa rareté.
Paris, janvier 1842.
[1] L’auteur de l’expérience de Barcelone doit être Salomon

de Caux, et non de Caus. Ce grand homme a toujours du
malheur, même après sa mort, son nom est encore tronqué.
Salomon, dont le portrait original et fait à l’âge de quarante-six
ans, a été retrouvé par l’auteur de la Comédie Humaine, à
Heidelberg, est né à Caux en Normandie.
INTRODUCTION.
On crie assez généralement au paradoxe, lorsque des savants,

frappés d’une erreur historique, essayent de la redresser; mais pour
quiconque étudie à fond l’histoire moderne, il est certain que les
historiens sont des menteurs privilégiés qui prêtent leurs plumes aux
croyances populaires, absolument comme la plupart des journaux
d’aujourd’hui n’expriment que les opinions de leurs lecteurs.
L’indépendance historique a beaucoup moins brillé chez les
laïques que chez les religieux. C’est des Bénédictins, une des
gloires de la France, que nous viennent les plus pures lumières en
fait d’histoire, pourvu toutefois que l’intérêt des religieux ne fût pas
au jeu. Aussi, dès le milieu du dix-huitième siècle, s’est-il élevé de
grands et de savants controversistes qui, frappés de la nécessité de
redresser les erreurs populaires accréditées par les historiens, ont
publié de remarquables travaux. Ainsi, M. de Launoy, surnommé le
Dénicheur de saints, fit une guerre cruelle aux saints entrés par
contrebande dans l’Église. Ainsi, les émules des Bénédictins, les
membres trop peu connus de l’Académie des Inscriptions et Belles-
Lettres, commencèrent, sur des points historiques obscurs, leurs
mémoires si admirables de patience, d’érudition et de logique. Ainsi,
Voltaire, dans un intérêt malheureux, avec une passion triste, porta
souvent la lumière de son esprit sur des préjugés historiques.
Diderot entreprit, dans cette visée, un livre trop long sur une époque
de l’histoire impériale de Rome. Sans la révolution française, la
critique, appliquée à l’histoire, allait peut-être préparer les éléments
d’une bonne et vraie histoire de France dont les preuves étaient
depuis si longtemps amassées par nos grands Bénédictins. Louis
XVI, esprit juste, a traduit lui-même l’ouvrage anglais par lequel
Walpole a essayé d’expliquer Richard III, et dont s’occupa tant le
siècle dernier.
Comment des personnages aussi célèbres que des rois ou des
reines, comment des personnages aussi importants que des
généraux d’armée deviennent-ils un objet d’horreur ou de dérision?
Entre la chanson sur Marlborough et l’histoire d’Angleterre, la moitié
du monde hésite, comme on hésite entre l’histoire et la croyance
populaire à propos de Charles IX. A toutes les époques où de
grandes batailles ont lieu entre les masses et le pouvoir, le peuple se
crée un personnage ogresque, s’il est permis de risquer un mot pour
rendre une idée juste. Ainsi, de notre temps, sans le Mémorial de
Sainte-Hélène, sans les controverses entre les royalistes et les
bonapartistes, il n’a tenu presque à rien que le caractère de
Napoléon ne fût méconnu. Quelques abbés de Pradt de plus, encore
quelques articles de journaux, et d’empereur, Napoléon passait ogre.
Comment l’erreur se propage-t-elle et s’accrédite-t-elle? ce mystère
s’accomplit sous nos yeux sans que nous nous en apercevions.
Personne ne se doute combien l’imprimerie a donné de consistance
et à l’envie qui s’attache aux gens élevés et aux plaisanteries
populaires qui résument en sens contraire un grand fait historique.
Ainsi, le nom du prince de Polignac est donné dans toute la France
aux mauvais chevaux sur lesquels on frappe. Et qui sait ce que
l’avenir pensera du coup d’État du prince de Polignac? Par suite
d’un caprice de Shakespeare, et peut-être fut-ce une vengeance
comme celle de Beaumarchais contre Bergasse (Begearss), Falstaff
est, en Angleterre, le type du ridicule, un nom qui provoque le rire; il
est le roi des clowns. Au lieu d’être énormément replet, sottement
amoureux, vain, ivrogne, vieux, corrupteur, Falstaff était un des
personnages les plus importants de son siècle, chevalier de l’ordre
de la Jarretière, et revêtu d’un commandement supérieur. A
l’avénement de Henri V au trône, sir Falstaff avait au plus trente-
quatre ans. Ce général, qui se signala pendant la bataille d’Azincourt
et y fit prisonnier le duc d’Alençon, prit en 1420 Montereau, qui fut
vigoureusement défendu. Enfin sous Henri VI, il battit dix mille
Français avec quinze cents soldats fatigués et mourants de faim!
Voilà pour la guerre. Si de là nous passons à la littérature, chez nous
Rabelais, homme sobre qui ne buvait que de l’eau, passe pour un
amateur de bonne chère, pour un buveur déterminé. Mille contes
ridicules ont été faits sur l’auteur d’un des plus beaux livres de la
littérature française, le Pantagruel. L’Arétin, l’ami de Titien et le
Voltaire de son siècle, a, de nos jours, un renom en complète
opposition avec ses œuvres, avec son caractère, et que lui vaut une
débauche d’esprit en harmonie avec les écrits de ce siècle, où le
drôlatique était en honneur, où les reines et les cardinaux écrivaient
des contes, dits aujourd’hui licencieux. On pourrait multiplier à l’infini
les exemples de ce genre. En France, et dans la partie la plus grave
de l’histoire moderne, aucune femme, si ce n’est Brunehault ou
Frédégonde, n’a plus souffert des erreurs populaires que Catherine
de Médicis; tandis que Marie de Médicis, dont toutes les actions ont
été préjudiciables à la France, échappe à la honte qui devrait couvrir
son nom. Marie a dissipé les trésors amassés par Henri IV, elle ne
s’est jamais lavée du reproche d’avoir connu l’assassinat du roi, elle
a eu pour intime d’Épernon qui n’a point paré le coup de Ravaillac et
qui connaissait cet homme de longue main; elle a forcé son fils de la
bannir de France, où elle encourageait les révoltes de son autre fils
Gaston; enfin, la victoire de Richelieu sur elle, à la journée des
Dupes, ne fut due qu’à la découverte que le cardinal fit à Louis XIII
des documents tenus secrets sur la mort d’Henri IV. Catherine de
Médicis, au contraire, a sauvé la couronne de France; elle a
maintenu l’autorité royale dans des circonstances au milieu
desquelles plus d’un grand prince aurait succombé. Ayant en tête
des factieux et des ambitions comme celles des Guise et de la
maison de Bourbon, des hommes comme les deux cardinaux de
Lorraine et comme les deux Balafré, les deux princes de Condé, la
reine Jeanne d’Albret, Henri IV, le connétable de Montmorency,
Calvin, les Coligny, Théodore de Bèze, il lui a fallu déployer les plus
rares qualités, les plus précieux dons de l’homme d’État, sous le feu
des railleries de la presse calviniste. Voilà des faits qui, certes, sont
incontestables. Aussi, pour qui creuse l’histoire du seizième siècle
en France, la figure de Catherine de Médicis apparaît-elle comme
celle d’un grand roi. Les calomnies une fois dissipées par les faits
péniblement retrouvés à travers les contradictions des pamphlets et
les fausses anecdotes, tout s’explique à la gloire de cette femme
extraordinaire, qui n’eut aucune des faiblesses de son sexe, qui
vécut chaste au milieu des amours de la cour la plus galante de
l’Europe, et qui sut, malgré sa pénurie d’argent, bâtir d’admirables
monuments, comme pour réparer les pertes que causaient les
démolitions des Calvinistes qui firent à l’art autant de blessures
qu’au corps politique. Serrée entre des princes qui se disaient les
héritiers de Charlemagne, et une factieuse branche cadette qui
voulait enterrer la trahison du connétable de Bourbon sous le trône,
Catherine, obligée de combattre une hérésie prête à dévorer la
monarchie, sans amis, apercevant la trahison dans les chefs du parti
catholique, et la république dans le parti calviniste, a employé l’arme
la plus dangereuse, mais la plus certaine de la politique, l’adresse!
Elle résolut de jouer successivement le parti qui voulait la ruine de la
maison de Valois, les Bourbons qui voulaient la couronne, et les
Réformés, les Radicaux de ce temps-là qui rêvaient une république
impossible, comme ceux de ce temps-ci qui cependant n’ont rien à
réformer. Aussi tant qu’elle a vécu, les Valois ont-ils gardé le trône. Il
comprenait bien la valeur de cette femme, le grand de Thou, quand,
en apprenant sa mort, il s’écria:—Ce n’est pas une femme, c’est la
royauté qui vient de mourir. Catherine avait en effet au plus haut
degré le sentiment de la royauté; aussi la défendit-elle avec un
courage et une persistance admirables. Les reproches que les
écrivains calvinistes lui ont faits sont évidemment sa gloire, elle ne
les a encourus qu’à cause de ses triomphes. Pouvait-on triompher
autrement que par la ruse? Toute la question est là. Quant à la
violence, ce moyen touche à l’un des points les plus controversés de
la politique et qui, de notre temps, a été résolu sur la place où l’on a
mis un gros caillou d’Égypte pour faire oublier le régicide et offrir
l’emblème du système actuel de la politique matérialiste qui nous
gouverne; il a été résolu aux Carmes et à l’Abbaye; il a été résolu
sur les marches de Saint-Roch; il a été résolu devant le Louvre en
1830, encore une fois par le peuple contre le roi, comme depuis il a
été résolu par la meilleure des républiques de La Fayette contre
l’insurrection républicaine à Saint-Merri et rue Transnonain. Tout
pouvoir, légitime ou illégitime, doit se défendre quand il est attaqué;
mais, chose étrange, là où le peuple est héroïque dans sa victoire
sur la noblesse, le pouvoir passe pour assassin dans son duel avec
le peuple. Enfin, s’il succombe, après son appel à la force, le pouvoir
passe encore pour imbécile. Le gouvernement actuel tentera de se
sauver avec deux lois du même mal qui attaquait Charles X et
duquel ce prince voulait se débarrasser par deux ordonnances. Ne
sera-ce pas une amère dérision? La ruse est-elle permise au pouvoir
contre la ruse? doit-il tuer ceux qui le veulent tuer? Les massacres
de la Révolution répondent aux massacres de la Saint-Barthélemi.
Le peuple devenu roi a fait contre la noblesse et le roi, ce que le roi
et la noblesse ont fait contre les insurgés du seizième siècle. Ainsi
les écrivains populaires, qui savent très-bien qu’en semblable
occurrence le peuple agirait encore de même, sont sans excuse
quand ils blâment Catherine de Médicis et Charles IX. Tout pouvoir,
comme le disait Casimir Périer en apprenant ce que devait être le
pouvoir, est une conspiration permanente. On admire les maximes
antisociales que publient d’audacieux écrivains, pourquoi donc la
défaveur qui s’attache en France aux vérités sociales quand elles se
produisent hardiment? Cette question explique à elle seule toutes
les erreurs historiques. Appliquez la solution de cette demande aux
doctrines dévastatrices qui flattent les passions populaires et aux
doctrines conservatrices qui répriment les sauvages ou folles
entreprises du peuple; et vous trouverez la raison de l’impopularité,
comme de la popularité de certains personnages. Laubardemont et
Laffemas étaient, comme certaines gens d’aujourd’hui, dévoués à la
défense du pouvoir auquel ils croyaient. Soldats ou juges, ils
obéissaient les uns et les autres à une royauté. D’Orthez aujourd’hui
serait destitué pour avoir méconnu les ordres du ministère, et
Charles IX lui laissa le gouvernement de sa province. Le pouvoir de
tous ne compte avec personne, le pouvoir d’un seul est obligé de
compter avec les sujets, avec les grands comme avec les petits.
Catherine, comme Philippe II et le duc d’Albe, comme les Guise
et le cardinal Granvelle ont aperçu l’avenir que la Réformation
réservait à l’Europe; ils ont vu les monarchies, la religion, le pouvoir
ébranlés! Catherine écrivit aussitôt, au fond du cabinet des rois de
France, un arrêt de mort contre cet esprit d’examen qui menaçait les
sociétés modernes, arrêt que Louis XIV a fini par exécuter. La
révocation de l’Édit de Nantes ne fut une mesure malheureuse qu’à
cause de l’irritation de l’Europe contre Louis XIV. Dans un autre
temps, l’Angleterre, la Hollande et l’Empire n’eussent pas encouragé
chez eux les bannis français et la révolte en France.
Pourquoi refuser de nos jours à la majestueuse adversaire de la
plus inféconde des hérésies la grandeur qu’elle a tirée de sa lutte
même? Les Calvinistes ont beaucoup écrit contre le Stratagème de
Charles IX; mais parcourez la France? en reconnaissant les ruines
de tant de belles églises abattues, en mesurant les énormes
blessures faites par les Religionnaires au corps social, en apprenant
combien de revanches ils ont prises, en déplorant les malheurs de
l’individualisme, la plaie de la France actuelle et dont le germe était
dans les questions de liberté de conscience agitées par eux, vous
vous demanderez de quel côté sont les bourreaux? Il y a, comme le
dit Catherine dans la troisième partie de cette Étude,
«malheureusement à toutes les époques des écrivains hypocrites
prêts à pleurer deux cents coquins tués à propos.» César, qui tâchait
d’apitoyer le sénat sur le parti de Catilina, eût peut-être vaincu
Cicéron, s’il avait eu des journaux et une Opposition à ses ordres.
Une autre considération explique la défaveur historique et
populaire de Catherine. L’Opposition en France a toujours été
protestante, parce qu’elle n’a jamais eu que la négation pour
politique; elle a hérité des théories des Luthériens, des Calvinistes et
des Protestants sur les mots terribles de liberté, de tolérance, de
progrès et de philosophie. Deux siècles ont été employés par les
opposants au pouvoir à établir la douteuse doctrine du libre arbitre.
Deux autres siècles ont été employés à développer le premier
corollaire du libre arbitre, la liberté de conscience. Notre siècle
essaye d’établir le second, la liberté politique.
Assises entre les champs déjà parcourus et les champs à
parcourir, Catherine et l’Église ont proclamé le principe salutaire des
sociétés modernes, una fides, unus dominus, en usant de leur droit
de vie et de mort sur les novateurs. Encore qu’elle ait été vaincue,
les siècles suivants ont donné raison à Catherine. Le produit du libre
arbitre, de la liberté religieuse et de la liberté politique (ne
confondons pas avec la liberté civile), est la France d’aujourd’hui.
Qu’est-ce que la France de 1840? un pays exclusivement occupé
d’intérêts matériels, sans patriotisme, sans conscience, où le pouvoir
est sans force, où l’Élection, fruit du libre arbitre et de la liberté
politique, n’élève que les médiocrités, où la force brutale est
devenue nécessaire contre les violences populaires, et où la
discussion, étendue aux moindres choses, étouffe toute action du
corps politique; où l’argent domine toutes les questions, et où
l’individualisme, produit horrible de la division à l’infini des héritages
qui supprime la famille, dévorera tout, même la nation, que
l’égoïsme livrera quelque jour à l’invasion. On se dira: Pourquoi pas
le tzar, comme on s’est dit:—Pourquoi pas le duc d’Orléans? On ne
tient pas à grand’chose; mais dans cinquante ans, on ne tiendra plus
à rien.
Ainsi, selon Catherine et selon tous ceux qui tiennent pour une
société bien ordonnée, l’homme social, le sujet n’a pas de libre
arbitre, ne doit point professer le dogme de la liberté de conscience,
ni avoir de liberté politique. Mais, comme aucune société ne peut
exister sans des garanties données au sujet contre le souverain, il
en résulte pour le sujet des libertés soumises à des restrictions. La
liberté, non; mais des libertés, oui; des libertés définies et
caractérisées. Voici qui est conforme à la nature des choses. Ainsi,
certes, il est hors du pouvoir humain d’empêcher la liberté de la
pensée, et nul souverain ne peut atteindre l’argent. Les grands
politiques qui furent vaincus dans cette longue lutte (elle a duré cinq
siècles) reconnaissaient à leurs sujets de grandes libertés; mais ils
n’admettaient ni la liberté de publier des pensées antisociales, ni la
liberté indéfinie du sujet. Pour eux, sujet et libre sont en politique
deux termes qui se contredisaient, de même que des citoyens tous
égaux constitue un non-sens que la nature dément à toute heure.
Reconnaître la nécessité d’une religion, la nécessité du pouvoir, et
laisser aux sujets le droit de nier la religion, d’en attaquer le culte, de
s’opposer à l’exercice du pouvoir par l’expression publique,
communicable et communiquée de la pensée, est une impossibilité
que ne voulaient point les Catholiques du seizième siècle. Hélas! la
victoire du calvinisme coûtera bien plus cher encore à la France
qu’elle n’a coûté jusqu’aujourd’hui, car les sectes religieuses et
politiques, humanitaires, égalitaires, etc., d’aujourd’hui, sont la
queue du calvinisme; et à voir les fautes du pouvoir, son mépris pour
l’intelligence, son amour pour les intérêts matériels où il veut prendre
ses points d’appui, et qui sont les plus trompeurs de tous les
ressorts, à moins d’un secours providentiel, le génie de la
destruction l’emportera de nouveau sur le génie de la conservation.
Les assaillants, qui n’ont rien à perdre et tout à gagner, s’entendent
admirablement; tandis que leurs riches adversaires ne veulent pas
faire un sacrifice en argent ou en amour-propre pour s’attacher des
défenseurs.
L’imprimerie vint en aide à l’opposition commencée par les
Vaudois et les Albigeois. Une fois que la pensée humaine, au lieu de
se condenser comme elle était obligée de le faire pour rester sous la
forme la plus communicable, revêtit une multitude d’habillements et
devint le peuple lui-même au lieu de rester en quelque sorte
divinement axiomatique, il y eut deux multitudes à combattre: la
multitude des idées et la multitude des hommes. Le pouvoir royal a
succombé dans cette guerre, et nous assistons de nos jours, en
France, à sa dernière combinaison avec des éléments qui le rendent
difficile, pour ne pas dire impossible. Le pouvoir est une action, et le
principe électif est la discussion. Il n’y a pas de politique possible
avec la discussion en permanence. Aussi, devons-nous trouver bien
grande la femme qui sut deviner cet avenir et qui le combattit si
courageusement. Si la maison de Bourbon a pu succéder à la
maison de Valois, si elle a trouvé la couronne à prendre, elle l’a due
à Catherine de Médicis. Supposez le second Balafré debout,
quelque fort qu’ait été le Béarnais, il est douteux qu’il eût saisi la
couronne, à voir combien chèrement le duc de Mayenne et les
restes du parti des Guise la lui ont vendue. Les moyens nécessaires
dont s’est servie Catherine, qui a dû se reprocher la mort de
François II et celle de Charles IX, morts tous deux bien à temps pour
la sauver, ne sont pas, remarquez-le, l’objet des accusations des
écrivains calvinistes et modernes? S’il n’y eut point
d’empoisonnement comme de graves auteurs l’ont dit, il y eut des
combinaisons plus criminelles: il est hors de doute qu’elle empêcha
Paré de sauver l’un, et qu’elle accomplit sur l’autre un long
assassinat moral. La rapide mort de François II, celle de Charles IX
si savamment amenée ne nuisaient point aux intérêts calvinistes, les
causes de ces deux événements gisaient dans la sphère supérieure
et ne furent soupçonnées ni par les écrivains, ni par le peuple de ce
temps, elles n’étaient devinées que par les de Thou, les L’Hospital,
par les esprits les plus élevés, ou par les chefs des deux partis qui
convoitaient ou qui défendaient la couronne et qui trouvaient de tels
moyens nécessaires. Les chansons populaires s’attaquaient, chose
étrange, aux mœurs de Catherine. On connaît l’anecdote de ce
soldat qui faisait rôtir une oie dans le corps de garde du château de
Tours pendant la conférence de Catherine et de Henri IV, en
chantant une chanson où la reine était outragée par une
comparaison avec la bouche à feu du plus fort calibre que
possédaient les Calvinistes. Henri IV tira son épée pour aller tuer le
soldat; Catherine l’arrêta, et se contenta de crier à l’insulteur:—Hé!
c’est Catherine qui te donne l’oie! Si les exécutions d’Amboise furent
attribuées à Catherine, si les Calvinistes firent de cette femme
supérieure l’éditeur responsable de tous les malheurs inévitables de
cette lutte, il en fut d’elle, comme plus tard de Roberspierre qui reste
à juger. Catherine fut d’ailleurs cruellement punie de sa préférence
pour le duc d’Anjou, qui lui fit faire bon marché des deux aînés.
Henri III, arrivé, comme tous les enfants gâtés, à la plus profonde
indifférence envers sa mère, se plongea volontairement dans des
débauches qui firent de lui ce que sa mère avait fait de Charles IX,
un mari sans fils, un roi sans héritiers. Par malheur, le duc
d’Alençon, le dernier enfant mâle de Catherine, mourut, et
naturellement. Catherine fit des efforts inouïs pour combattre les
passions de son fils. L’histoire a conservé le souvenir du souper de
femmes nues donné dans la galerie de Chenonceaux, au retour de
Pologne, et qui ne fit point revenir Henri III de ses mauvaises
habitudes. La dernière parole de cette grande reine a résumé sa
politique, qui d’ailleurs est si conforme au bon sens, que nous
verrons tous les cabinets la mettant en pratique en de semblables
circonstances.—Bien coupé, mon fils, dit-elle quand Henri III vint à
son lit de mort lui annoncer que l’ennemi de la couronne avait été
mis à mort, maintenant il faut recoudre. Elle indiquait ainsi que le
trône devait aussitôt se raccommoder avec la maison de Lorraine et
s’en servir, seul moyen d’empêcher les effets de la haine des Guise,
en leur rendant l’espoir d’envelopper le roi; mais cette persistante
ruse de femme et d’Italienne qu’elle avait toujours employée, était
incompatible avec la vie voluptueuse de Henri III. Une fois la grande
mère morte (mater castrorum), la politique des Valois mourut.
Avant d’entreprendre d’écrire l’histoire des mœurs en action,
l’auteur de cette Étude avait patiemment et minutieusement étudié
les principaux règnes de l’histoire de France, la querelle des
Bourguignons et des Armagnacs, celle des Guise et des Valois, qui,
chacune, tiennent un siècle. Son intention fut d’écrire une histoire de
France pittoresque. Isabelle de Bavière, Catherine et Marie de
Médicis, ces trois femmes y tiennent une place énorme, dominent du
quatorzième au dix-septième siècle, et aboutissent à Louis XIV. De
ces trois reines, Catherine est la plus intéressante et la plus belle.
Ce fut une domination virile que ne déshonorèrent ni les amours
terribles d’Isabelle, ni les plus terribles encore, quoique moins
connues, de Marie de Médicis. Isabelle appela les Anglais en France
contre son fils, aima le duc d’Orléans, son beau-frère, et
Boisbourdon. Le compte de Marie de Médicis est encore plus lourd.
Ni l’une ni l’autre, elles n’eurent de génie politique. Dans ces études
et dans ces parallèles, l’auteur acquit la conviction de la grandeur de
Catherine: en s’initiant aux difficultés renaissantes de sa position, il
reconnut combien les historiens, influencés tous par les protestants,
avaient été injustes pour cette reine; et il lui en est resté les trois
esquisses que voici, où sont combattues quelques opinions erronées
sur elle, sur les personnages qui l’entouraient et sur les choses de
son temps. Si ce travail se trouve parmi les Études
philosophiques, c’est qu’il montre l’esprit d’un temps et qu’on y voit
clairement l’influence de la pensée. Mais avant d’entrer dans l’arène
politique où Catherine se voit aux prises avec les deux grandes
difficultés de sa carrière, il est nécessaire de présenter un précis de
sa vie antérieure, fait au point de vue d’une critique impartiale, afin
qu’on embrasse le cours presque entier de cette vaste et royale
existence, jusqu’au moment où commence la première partie de
l’Étude.
Jamais il n’y eut, dans aucun temps, dans aucun pays et dans
aucune famille souveraine, plus de mépris pour la légitimité que
dans la fameuse maison des Medici (Méditchi), dont, en France, le
nom se prononce Médicis. On y avait sur le pouvoir la même
doctrine qu’aujourd’hui professe la Russie: tout chef à qui le trône
va, devient le vrai, le légitime. Mirabeau avait raison de dire: «Il n’y a
eu qu’une mésalliance dans ma famille, c’est celle des Médicis;» car,
malgré les efforts des généalogistes à gages, il est certain que les
Médicis, avant Avérard de Médicis, gonfalonier de Florence en 1314,
étaient de simples commerçants de Florence qui devinrent très-
riches. Le premier personnage de cette famille, qui commence à
occuper une place importante dans l’histoire de la fameuse
République toscane, fut Salvestro de Médicis, devenu gonfalonier en
1378. De ce Salvestro, naquirent deux fils, Cosme et Laurent de
Médicis.
De Cosme sont descendus Laurent le Magnifique, le duc de
Nemours, le duc d’Urbin, père de Catherine, le pape Léon X, le pape
Clément VII, et Alexandre, non pas duc de Florence, comme on le

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Schwartzâ€™s Principles of Surgery -

Editor-in-Chief John G. Hunter, MD, FACS, FRCS Edin(Hon.)

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Contributors/vii 13. Physiologic Monitoring of the

29. Colon, Rectum, and Anus ..............................1259

Darren B. Abbas, MD Dana K. Andersen, MD, FACS

Chapter 28, Small Intestine

Haile T. Debas, MD, FACS Nabil A. Ebraheim, MD

Director of Research, Division of Cardiothoracic Disease, and Precision Surgery

Translational Science Institute (CTSI) Life Sciences

Toledo, Ohio Toledo, Ohio

Chapter 54, Web-Based Education and Implications of Pittsburgh, Pennsylvania

Medicine & Dentistry

We, the editors of this leading textbook of surgery,

Introduction 3 Choosing to Become a Leader / 11 Evaluation of Surgeon Performance / 16

INTRODUCTION formal curricula focused on teaching leadership principles, it is

The fundamental principles of leadership

motivation. For the surgeon-leader, it is critical to know that

agenda. This concept, based on Simon Sinek’s Start With Why,

Why Limbic Brain

When a leader's vision appeals to “why,” it triggers an emotional

Figure 1-6. When leaders seek to generate belief in their vision,

of separate anatomical levels in the human brain. The neo- Willingness

surgeons and surgical trainees a means to acquire new knowl-

Board of Surgery requires all surgeons to complete meaningful

Low education, low High education, low

service value (Ex: Waiting during service value

High education, high

MENTORING AND DEVELOPMENT ­institutions.145 Mentoring provides benefits to the mentors

Au château de Saché, novembre et décembre 1831.

A MONSIEUR LE MARQUIS DE PASTORET,

Quand on songe au nombre étonnant de volumes publiés

[1] L’auteur de l’expérience de Barcelone doit être Salomon

On crie assez généralement au paradoxe, lorsque des savants,

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MENTORING AND DEVELOPMENT institutions.145 Mentoring provides benefits to the mentors