EACTS Presidential Address The versatile beauty ... - Oxford Academic

European Journal of Cardio-Thoracic Surgery Advance Access published November 12, 2014

EACTS Presidential Address The versatile beauty of the hand: mysterious, powerful and ingenious† Paul E. Van Schil* and Jan Gielis Department of Thoracic and Vascular Surgery, Antwerp University Hospital and Antwerp Surgical Training and Research Center (ASTARC), Antwerp University, Antwerp, Belgium * Corresponding author. Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Wilrijkstraat 10, Edegem (Antwerp) B-2650, Belgium. Tel: +32-3-8214360; fax: +32-3-8214396; e-mail: [email protected] (P.E. Van Schil).

Keywords: Hand • History • Art • Patient care • Research • Education

Let me start by saying what a great honour it has been for me to serve as your president over the past year. In fact, it has been a very stimulating year for me. The EACTS is an extremely well-organized society, with a dedicated staff in Windsor running so smoothly under the excellent guidance of Kathy, and working with them in organizing a large cardiothoracic meeting such as the present one has made me realize that the work is hard but certainly rewarding. Equally, it has also been a very pleasurable year, as I received a lot of support from the secretary-general Pieter, my friends and colleagues of the thoracic domain, and all the members of the EACTS council. Also special thanks to Alan Sihoe, who was of great help in the preparation of this address. I am certainly indebted to my predecessor José Pomar, who prepared me very well to cope with the unique challenges of leading one of the most important surgical organizations in the world. But above all else, I must thank my wife and family for their endless support. From personal experience, José Pomar told me that the most stressful moment of being the president of EACTS is delivering the presidential address at the annual meeting. I now understand what he means! But there are also some peculiar features which make this address quite distinctly enjoyable. For a start, you do not have to send in an abstract or a completed paper well in advance of the meeting. You get a very nice introduction before you even come to the stage—thank you Martin for your extreme kindness. As you give this speech, there is no predefined structure and you get plenty of time without any orange or red lights. And for a thoracic surgeon, the audience is somewhat larger than what you would expect for a regular session. In fact, I had thought that the most difficult part of this presidential address would be to find a suitable subject, because the subject is completely free and so many interesting subjects have been addressed before. But even here I was fortunate because I did not have to look too far for inspiration. I would like to take you to my home city where I was born, Antwerp, Belgium. We are not a very big city but we do have a uniquely international and multicultural outlook, not only because we have a large port but also because of our very rich cultural history. Coming to my specific subject, there is a very nice legend † Presented at the 28th Annual Meeting of the European Association for CardioThoracic Surgery, Milan, Italy, 11–15 October 2014.

about the origin of the name Antwerp, ‘Antwerpen’ in Flemish, which is clearly shown in this statue by Jef Lambeaux in front of our city hall, dating from 1887 (Fig. 1). As for the story itself, we have to go back to the Roman period. At that time our river Scheldt was dominated by a giant called Antigone and all ships sailing to Antwerp had to pay a huge amount of tax to get through. This changed when Brabo, a small but brave Roman soldier, killed the giant, cut its hand and threw it into the river, hence the name ‘hand-werpen’ or throwing the hand. As you might expect, Antwerp is now full of hands which have become one of the symbols of our city. We even have a local speciality called ‘Antwerp hands’, which are delicious cookies available in many specific tastes and forms and they symbolize friendship. When you attend the congress dinner tomorrow, you will be able to taste them while making new friends. A nice sculpture representing a large hand is found on the Meir, which is our main shopping street. It is part of a large sculpture called l’Ecoute that can be found in Paris close to the Forum des Halles. Another rather special, cut hand can be found in the castle of Gruyère in Switzerland, where we were on holidays. A lot of stories surround this remarkable hand, but recent analysis shows this slender hand to originate from an Egyptian mummy, which has been extremely well preserved. Going even further back in time, what distinguishes mankind from other mammalian species is our progressive upright position, which unleashes our hands to work miracles. It is our exceptional manual dexterity that has allowed our current mastery of the planet. So, not surprisingly, throughout the history of art and science, the human hand has played a predominant role. The evolutionary and the cultural meaning of the hand for mankind is nicely described in the book ‘The Finger’ by Angus Trumble (Editor Farrar, Straus and Giroux, 2010, New York, USA), originating from a lecture given for orthopaedic surgeons in Australia. Some of the examples I will show you are derived from this book. The earliest of all surviving man-made drawings are of hands and fingers, which can be found on the walls of the caves in Altamira, Spain and in Pech-Merle in the district of Lot in France, the latter being approximately 20 000 years old. Probably, the most famous depiction of hands is the marvellous creation of man painted by Michelangelo Buonarotti on the

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

PRESIDENTIAL ADDRESS


European Journal of Cardio-Thoracic Surgery (2014) 1–4 doi:10.1093/ejcts/ezu433

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P.E. Van Schil and J. Gielis / European Journal of Cardio-Thoracic Surgery

Figure 1: The statue by Jef Lambeaux (1887) in front of city hall of Antwerp demonstrating the legend of the giant Antigone and Roman soldier Brabo, who cut the hand of the giant and threw it into the river Scheldt, from which the name Antwerp (hand – werpen) originates.

ceiling of the Sistine Chapel around 1512. Two magnificent hands are put in the centre: the somewhat older hand of God the Father with the index finger pointing to Adam representing transfer of force and energy, and the awakening left hand of the first man, symbolizing incipient life. The hand is an extremely complicated anatomical structure requiring a delicate interplay between specifically shaped bones, articulations, ligaments, muscles, tendons, blood vessels and nerves. In our surgical speciality, hands are extremely important to perform the highly precise technical acts necessary to complete every operation, from a minor biopsy to a hugely challenging airway reconstruction. Not only are fine technical skills required, but also a balanced interaction between our brain and the hands executing the complex commands. I remember one of my previous vascular teachers observing us young residents as we were struggling with a difficult intervention. He asked us the specific question ‘What’s the difference between your hands and my hands?’ His answer was ‘My hands are connected to a brain’. Our hand is called ‘the tool of tools’ and the opposition of thumb and index finger is unique to mankind. The genius of Rembrandt van Rijn is shown in the painting ‘Anatomy Lesson of Dr Nicolaes Tulp’ from 1632. Although anatomically not completely correct, the surgeon takes up the tendons of the cadaver’s forearm that exactly execute the opposition of the thumb and index finger, which made it possible for mankind to ascend to the top of the evolutionary

tree. Moreover, the free left hand of Dr Tulp offers a clear demonstration of the functioning of the same tendons. This great city of Milano, where our EACTS annual meeting is being held for the first time, offers beautiful examples of the importance of hands and fingers. In the world famous ‘Last Supper’ by the hand of Leonardo da Vinci, the dramatic moment of Jesus’ betrayal can be sharply felt as stated in the Bible ‘But the hand of him who is going to betray me is with mine on the table’. The hands of the disciples are clearly put on the foreground by Leonardo. Peter is looking angry and holds a knife pointed away from Christ. Besides him sits Judas, put more in the shadow and holding a purse. He is also tipping over the salt cellar, which may be related to the near-Eastern expression ‘to betray the salt’ meaning to betray one’s Master. These details are more apparent in the copy of Giampietrino made around 1520 and in another nice copy found in the abbey of Tongerlo in Belgium. With our hands we are able to perform a multitude of tasks, from very simple to incredibly complicated ones. We can shape, create, build, touch, indicate, direct, approve, and as with many splendid things, unfortunately, also disapprove, beat, disrupt, hurt, destroy and kill. Should we not use our hands for what they have been created for, to further advance our species? Our hands are ideally suited to reach out and embrace other people to obtain a sense of togetherness, common being and unification. Let us apply this to the three pillars of our academic profession. First and foremost is patient care, our core business. Compared with the period when I was a resident, which in fact was in a previous century, the image of the forceful and almost almighty head of the department of surgery is outdated and does not exist anymore. As pointed out by Doug Wood in his superb presidential address at the Society of Thoracic Surgeons (STS) annual meeting in January of this year, our vertically organized departments are moving towards a more horizontal structure. One of the main tasks of a leader is to bring everybody at each level of his department together, and define common goals and interests, subsequently shaping the way to reach the predefined endpoints. Treatment of patients does not depend on the opinion of one person anymore. Every large, self-respecting medical society has authoritative guidelines dealing with diagnosis and treatment of every major disease process its speciality is tasked to manage. These are quickly adopted by national and regulatory bodies. Almost every patient is discussed within a multidisciplinary board and we have seen the birth of heart and lung teams. Specific clinical pathways for disease management have been designed and exceptions to the rules are still allowed, but have to be accounted for. This remains a difficult point for many surgeons as surgery is a highly individualized profession; in fact, there is only one person who can perform a specific operation and take leadership of a complex procedure with its inherent risks of intraoperative technical difficulties and subsequent complications. This is in sharp contrast to the more contemplative art of internal medicine where several colleagues can together interpret laboratory and imaging results, prescribe specific pharmacological treatments, or even discuss indications for surgical treatment. However, I have to admit that in recent years this distinction is becoming vaguer as many traditional disciplines of internal medicine and imaging modalities are developing clearly technically based procedures which are complementary to or in some cases even replacing our so-called aggressive surgical acts. Cardiologists are becoming more and more invasive, not only performing percutaneous, coronary interventions and procedures but also engaging in valve repair and replacement. With the advance of endosonographic

techniques, pulmonary physicians nowadays are able to play an important part in staging and restaging of lung cancer. With endobronchial stenting, valves and laser applications, palliative treatment of lung cancer and even emphysema surgery have become part of their armamentarium. Interventional radiologists do no’t limit themselves to the production and interpretation of nice threedimensional images, but they are becoming very skilled in introducing catheters and sheaths in every major artery for thrombolytic therapy, inflation of balloons, creation of shunts and repair of aneurysms, even tough ones. In this changing environment, cardiothoracic surgeons need to get accustomed to reaching out to other colleagues and working— hand-in-hand—in an increasingly multidisciplinary setting. Probably, in the next decades, we will witness the birth of new specialities incorporating previous subdisciplines of internal medicine, radiology and surgery, between which the borders are progressively dissolving. Our second pillar is research. In my opinion, not only clinical but also basic research should remain an integral part of our speciality as cardiothoracic surgeons are ideally placed to build bridges between basic science and our clinical practice. For this reason, we have to provide a solid base and give a hand to our younger researchers, which for EACTS has always been a priority. As the future of our speciality depends on the next generation of surgeons including young fellows, I would like to hand over to Jan Gielis, one of our most promising Antwerp students and currently performing basic surgical research on ischaemia/reperfusion injury in lung parenchyma, which will be presented at this meeting. I asked him to give his impressions and ideas on surgical research performed by young surgeons in training. Thank you, Professor Van Schil, for this most generous introduction. Ladies and gentlemen, it is a great honour for a junior doctor like me to stand here before an audience of such esteemed surgeons. Following Professor Van Schil’s theme of hands, I feel privileged to share with you all the insights gained when a surgical trainee’s hands are laid upon basic surgical research. For a young physician emerging from the purely clinical environment of medical school, basic research means stepping well outside one’s comfort zone. For me, this became painfully clear the first time I tried to hold a pipette in my hands and spilled the contents of a €500 bottle all over the laboratory bench. This was to the enormous amusement of the more hardened lab rats, who had already been curious as to when my first mess-up would happen. It was obvious that my hands were, at that time, better suited to grab a needle holder rather than a reagent tube. During those difficult first moments, I asked myself the same question a physicist asked me when I walked into a spectroscopy meeting for the first time: ‘What the hell are you doing here?’ Luckily, I was able to bring into practice those qualities that we learn from our mentors when facing unexpected situations in the operating theatre: to adapt, to improvise, to keep our heads cool and—above all—to keep our hands steady. After a few months, I developed the ‘Fingerspitzengefühl’ necessary to bring my first ‘real’ experiment to a more or less satisfying conclusion. Working together with more experienced lab staff can indeed be quite challenging in the beginning. For a junior doctor, experimental research is also a journey to strange departments and seeing their alien points of view. During the last year, I forged stimulating collaborations with the peculiar people educated in pharmaceutical sciences, biomedical sciences, even physics and chemistry. In the clinic, we sometimes speak to them over the phone, but we rarely see these people. Working with them allowed me to understand things from their perspective, and even begin to empathize with

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our laboratory colleagues when yet another belligerent surgeon is barking at them over the phone. But not only do you develop new acquaintances and relationships, some existing relationships tend to change during a scientific fellowship. We junior doctors, as aspiring surgeons, have a curious relationship with our mentors. On the one hand, you look up to your chief as a divine source of knowledge, art and craftsmanship. On the other hand, he or she is the one whose righteous wrath you fear when you have made a mistake or overlooked an important medical issue. As a research fellow, a remarkable transformation in this relationship occurs. In my opinion, by doing research one develops a more mature relationship with one’s mentor. Ultimately, you are becoming an expert in the scientific field you chose as a subject. Because you are constantly involved with your research, you learn to discuss strategies, voice opinions and sometimes even politely disagree with your patron. Now, when the trainee rejoins the mentor in the clinic and the operating theatre, there is a subtle change to the old adage of master and disciple. Now, interspersed with the firm corrections and criticisms, the master gives the occasional positive ‘thumbs up’ to acknowledge the disciple’s progress in the path he or she has chosen, and the disciple can now better grasp the master’s feedback that ensures the hard lessons of each working day are well learned. My experience from this research fellowship has made me appreciate more than ever our mentors and teachers who generously pass onto us not only their fine surgical skills and great clinical insight, but also a profound appetite for scientific research. I am very grateful to the University of Antwerp and the Research Foundation of Flanders whose grant of a 4-year fellowship has given my own hands the opportunities to engage in the most fascinating research, and also the skills to carry such research even further in the future. Our third building stone is education, principles of which have changed over the last decade by profound innovations in the way we teach and approach students. Our own university in Antwerp is currently ranked within the 10 best young universities by Chaucquerelli-Symonds top 50. Among the innovations that have won us this honour is the adoption of ‘life-long learning’ as one of our most important educational principles. Again, the border between masters and disciples, teachers and students is becoming less well defined. We all have to increase our knowledge, not only when we are students, but also when starting our clinical practice, and even for a lifetime thereafter. Ex cathedra teaching is currently very limited although I am convinced that medical students need a solid base on which they can build further to expand their understanding and knowledge of physiopathology and disease processes in order to become well-trained physicians. Teaching in smaller groups, early introduction of bedside teaching, self-study, and feedback and interactive sessions have been slowly introduced to get students more involved at an early stage. The residency training programme in Flanders has evolved to develop mastery in multiple skill sets, not only as a medical doctor but also as a scientist, manager and communicator. This programme culminates in the presentation of a master thesis which has to be defended in front of a jury. In this way, we train our residents to be better prepared to manage all aspects related to our speciality and to better cope with future challenges. Unfortunately, training in cardiothoracic surgery is not uniform across the world, which limits exchange of knowledge and students between the different European countries. Organizations such as EACTS have a vital



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Figure 2: Hands photographed by Jan Kersschot, MD (www.studioinspiration. be).

responsibility to promote and lead training programmes, educational and postgraduate courses, and European professional board examinations. Re-accreditation of surgeons and its specific criteria are a hotly debated topic in many European countries. So, many educational challenges still lie ahead of us. To meet these challenges, we also have to reach out to join hands with other societies including the American and Asian associations, and work together as we have many common interests and goals. In our discussions with other societies and associations, the primary goal is to advance scientific knowledge, education and teaching in order to train and prepare the young generation for their profession and the future challenges they will have to cope with. For those of us who serve in an executive function in such national and international societies, let us not concentrate on individual conflicts and personal interests, but instead let us focus on the major responsibility we have towards the memberships of these societies. Our hands are wonderful instruments; in fact, they are our most important tool, cheap, easy to sterilize, reusable thousands of times and not to be replaced by any other instruments. For health economists, a better cost/benefit ratio is hard to find. I like to tell the residents that we ‘see more with our fingers than with our eyes’, especially when nodules are difficult to localize deep inside the lung parenchyma or when we can palpate more lung metastases than we could see on a preoperative chest CT scan. Merely looking at the hands of our patients can provide us a lot of valuable information. It is rather strange to observe that contemporary artists are still fascinated by hands. Dr Jan Kersschot is a general practitioner in Antwerp and we were fellow students at the Antwerp University. He is also an artist and makes extremely touching photographs. With his permission I would like to show you a short video including some wonderful pictures of his patients’ hands (Fig. 2). So, I could paraphrase by stating ‘show me your hands and I tell you who you are’. This year we commemorate in Belgium the start of the Great War of 1914–18 in which my grandfather participated as soldier. Although the small country Belgium wanted to stay neutral, it was forced to take part as Germany had planned to invade France

Figure 3: The sculpture of hands by Willem Vermandere.

through Belgium. In October 1914, the relatively small Belgian army had withdrawn behind the Yser river close to the coast. The advancing German army could only be stopped by opening the locks and sluices close to the North Sea putting the Yser plane completely under water. During a prolonged trench warfare, a terrible slaughter took place and for the first time toxic gasses were used. Traces of this Great War are still visible today, also influencing artists living in this area. Willem Vermandere is not only a well-known singer but also a sculptor reminding us of the absurdity of any war, something we still have to learn in this new century. Remarkably, many of his sculptures are focused on hands coming together and intertwining in different ways, conveying the message that hands that meet and join forces are the best remedy against further disasters (Fig. 3). I would like to end with a special hand salute which refers to a sacred hand position used by ancient Jewish priests. It was popularized by Mr Spock in the series Star Trek, which became highly successful when I was a young student. This Vulcan greeting means ‘Live long and prosper’ and to my successor Martin Grabenwöger I would say all the best. I wish you a highly successful year as you explore strange new challenges, seek out new opportunities and new directions, and boldly go where no EACTS president has gone before.