Most physicians freely give their time and energy because it is an integral part of what it means to be a physician. Dr Cohen went on to further state that students should be exposed to community service as a critical part of their medical training, and that faculty should "model the tenets of professionalism that we wish to pass on to our trainees."²

Volunteerism is a philosophy that directs us as physicians to share our acquired skills and expertise and, of our own volition and without any expectation of financial compensation, to teach others who are less informed. To successfully assist in improving health care worldwide, we must focus our efforts on teaching those who will serve as future teachers. We cannot and should not expect that our ways are the best or uniformly apply in all situations. Imposing our knowledge and skill inappropriately can have disastrous consequences. This was brought into great clarity by a recent personal experience of Dr Eckhauser’s. A close and dear friend and colleague has devoted much of his adult life to helping underserved populations in Africa. He invited Dr Eckhauser to spend time with him in Nigeria, working in a mission hospital that he and other volunteers had established with American-based support. The health conditions were deplorable: excrement from individual and group dwellings drained into open sewers, and safe, sanitized drinking water and refrigeration to preserve meats and vegetables were not available. Injuries and illnesses that we would consider mundane were often lethal because the resources necessary to treat them were not available. There were no computed tomographic scanners, very limited supplies of antibiotics or safe blood for transfusion, and no technology to measure conventional laboratory studies, clotting factors, or blood gases. One afternoon, a young woman who had suffered a lye stricture of the esophagus some years earlier came to the clinic with a real problem. The gastrostomy tube that had been placed at the time of the initial injury to provide nutrition had completely deteriorated. She was otherwise healthy and was thought (by Dr Eckhauser) to be a suitable candidate for esophageal replacement. Dr Eckhauser offered to assist the chief of surgery at the hospital with what he hoped would be a smooth and rewarding achievement given the patient’s circumstances. The procedure technically went well. However, the patient developed postoperative pneumonia and ultimately required endotracheal intubation, assisted ventilation, and placement of a tube thoracostomy for a pneumothorax. Suitable antibiotics were not available. Reallocation of 1 of 2 functioning anesthesia machines to assist this patient would have resulted in the cancellation of procedures that had been scheduled months or years earlier. The surgeons did their best, but the patient ultimately died. The staff assisting Dr Eckhauser in treating the patient were tolerant of the outcome, but Dr Eckhauser was crushed. While the procedure was a success, their patient died. The surgeons’ technical virtuosity was simply not enough. They (Dr Eckhauser in particular) had grossly underestimated the support necessary to treat complications of such an extensive procedure. In parts of Africa, lye strictures of the esophagus are seen commonly, and conventional treatment consists of a permanent gastrostomy tube. The local surgeons were polite, but in retrospect, they showed little enthusiasm for techniques of esophageal reconstruction or replacement. Their skepticism stemmed from a clear understanding of local conditions and resource constraints. It became quite clear that Dr Eckhauser’s function was not to convert the local surgeons to his way of thinking, but to better understand their resource constraints and therefore teach them how to adapt and modify western technology to treat common and remediable illnesses and conditions. The experience reminded us of an old adage: "If you give a man a fish, he will eat for a day; if you teach him how to fish, he will eat for the rest of his life." Our presence in any underserved country is transient, and our influence is therefore limited. The greatest impact that physician volunteers can exert on poor but changeable health care situations is to help our colleagues learn to help themselves and, in so doing, to help their people and their country. The colleague, friend, and mentor understood this reality and, knowing that Dr Eckhauser’s intentions and zeal were honorable, helped him to learn a life lesson.

Volunteerism can transform people and produce skills and opportunities that would not have been learned or taken advantage of elsewhere, especially in traditional residency training programs. One has the opportunity to listen, to become more observant, and to use scarce resources to tackle difficult problems in an innovative manner. Working in a resource-scarce area with a diverse health care team helps one to become more accepting and tolerant of different cultures, and in many experiences, like Dr Eckhauser’s, to learn the true meaning of the term humility. Providing volunteer services is much like taking a course in human bioethics, and many of the same concerns apply, including classical vs alternative medical practices, ethnic and cross-cultural sensitivity, and appropriate use of scarce resources and life-sustaining treatments. Volunteerism offers us the opportunity to rediscover why we as surgeons do what we do and to reinvigorate us as health care practitioners. As volunteers and professionals, our recognized obligations include a commitment to lifelong learning, accountability to our patients and to the worldwide health care community, and a commitment as educators to model ethical and humanitarian behavior among our colleagues and trainees.

The American College of Surgeons, Chicago, Ill, through the Board of Governor’s Committee on Socioeconomic Issues, closely examined the extent of volunteer involvement among its members. The study³ concluded that many surgeons consider volunteerism an integral part of their identity. Based on this very positive response, the College created Operation Giving Back, a resource designed to serve as a

comprehensive resource center where surgeons can find the information they need to investigate and participate in volunteer opportunities, and to provide a source of inspiration and education for all parties interested in surgical volunteerism.³

Volunteerism is altruistic, and it is viewed by most physicians as the right thing to do. Unfortunately, many barriers continue to exist, including family obligations, lack of support from employers (or resistance from partners who would have to take responsibility for a disproportionate part of the group’s workload), and concerns about personal finances and safety. Despite these obstacles, some of which are real and others self-imposed, opportunities abound for volunteerism both here and abroad. In a recent presentation in 2002 to the American Surgical Association, Beverly, Mass, Haile Debas, MD, stated quite emphatically that "surgery is a noble profession in a changing world." Dr Debas immigrated from a small village in Eritrea, one of the poorest countries in Africa, struggled against many sociopolitical and ethnic obstacles, and eventually achieved a level of success that he could not have imagined as a younger man. He cited the attributes of a progressive 21st-century health care system, including patient safety and effective evidence-based practice that is respectful of each patient’s individual needs, values, and preferences and is timely, cost sensitive, efficient, and equitable across all sex, ethnic, and sociopolitical barriers.⁴ He predicted that the necessary changes would occur, but only if surgeons adopted a proactive philosophy and became participants rather than spectators in the transformation process. In a somewhat dated but very relevant article, Scheier⁵ indicated that the proof of everyday ethics is in the doing, not just the saying:

All leadership individuals and organizations (including surgery) adequately imitate volunteers insofar as they regularly treat their own colleagues, constituents, clients, and publics with consideration, caring and concern; with patience where needed; with respect and understanding always.⁵

The applicant pool for medicine has diminished recently, perhaps influenced by concerns about how the challenges of the future will be addressed. In addition, other studies showed that the number of applicants to general surgery residency programs had dropped 30% over the past 9 years.⁶ Several leaders in surgery indicated that "perceived threats to lifestyle" significantly influenced the career choices of medical students. We believe that this conclusion was overly simplistic. The explanation for this downward trend is multifactorial, and it includes several sources of discouragement: loss of decision-making autonomy, concerns about income and debt repayment, and an increasing perception that physicians are more oppressed than respected as guardians and protectors of the health care system. We can no longer afford to sit back and watch our ranks be decimated by apathy and job dissatisfaction. If we wish to increase the attractiveness of medicine and to recruit bright individuals with the same humanistic idealism that afflicted us all as young physicians, the relationship between teachers and learners of medicine will need to be critically reevaluated and changed. This paradigm shift was emphasized in a wonderful address given by Dr Cohen to the Association of American Medical Colleges, Washington, DC, in 2001:

We must close the gap between rhetoric and reality, between what kind of doctors we say we want them to become, and what kind of doctors we actually teach them how to be.⁷

Unfortunately, our learning environments tend to spawn objectivity, detachment, and wariness. If, as dedicated teachers of medicine, we can return to our roots and act rather than simply verbalize the humanistic ideals and virtues that attracted us to medicine in the first place, we will insure the future of medicine as a moral enterprise. In so doing, we will fulfill the legacy left to us by Hippocrates more than 2000 years ago. What better way to sustain an enduring commitment to the dignity and worth of every individual than through surgical volunteerism. The question is not whether we should incorporate the principles of volunteerism into our surgical training curricula; rather, can we afford not to?

AUTHOR INFORMATION
Correspondence: Dr Eckhauser, Department of Surgery, Johns Hopkins Hospital, 600 N Wolfe St, Blalock 1253, Baltimore, MD 21287 (feckhau2{at}jhmi.edu).