Historical Notes on the Founding of the Surgical Palliative Care Society

Historically, surgery as a discipline within medicine has to a great degree emerged out of the crucible of trauma and military conflict. Surgeons have always had a special concern for the products of violence—both wounds and the wounded. ¹ Two recent articles have provided excellent summaries of the development of the surgical palliative care movement. ² This essay will first highlight some of the contributions of various leaders and organizations in bringing this movement to life as well as trace the lineage of the Surgical Palliative Care Society within this process.

From its inception, the modern hospice and palliative care movement has benefited from the special concern of surgeons for human suffering. While Dame Cicely Saunders, as nurse, social worker, and physician brought her unique interdisciplinary understanding to hospice, Dr. Balfour Mount as a urologic oncologist brought the sensibilities and deep empathy of a compassionate surgeon, who in the encounter with suffering must at times be willing to cause suffering to relieve it. ³ The power of naming must never be underestimated—by coining the term palliative care Dr. Mount created a path by which the relief of suffering, wherever it might be found within the trajectory of serious illness, would again become the legitimate concern of medicine. Coming from a surgeon, palliative care represents both a challenge and much-needed corrective to surgical hubris. The intoxicating promise of cure offered by increasingly sophisticated operations does not justify ignoring the suffering of the surgical patient whose cure is often pursued with such single-minded enthusiasm.

A generation later, by the late 1990s, two American surgeons drawn separately to hospice work joined forces as they considered how best to share their insights gained from caring for the dying with the larger surgical community. ⁴ Dr. Geoffrey Dunn and Dr. Robert Milch (Figure 1) found a responsive and supportive audience among the leadership of the American College of Surgeons (ACS). ⁵ Fertile ground had already been prepared by the surgical ethics community so that the first introduction of palliative care to the larger world of surgery came in the form of an abstract ethical debate in 1997—practical palliative care would come later. The strong interest in surgical ethics and the emerging discipline of surgical outcomes research helped create a space in which surgical palliative care could also grow. ⁶ Through the persistent efforts of Dr. Dunn and Dr. Milch, the generous assistance of non-surgeon palliative care consultants, and with the combined support of the American College of Surgeons’ Division of Education and the Robert Wood Johnson Foundation, the RWJ-ACS Surgical Palliative Care Workgroup was formed. The workgroup (later taskforce) met for the first time on September 10, 2001. ⁷ OPEN IN VIEWER

A flurry of activity followed the formation of the taskforce including a report for the field in 2003, the ACS statement on principles of palliative care in 2005, a large series of articles on palliative care for surgeons published in the Journal of the American College of Surgeons between 2001 and 2005 (with the enthusiastic support and expert assistance of its executive editor, Wendy Cowles Husser), regular symposia on palliative care at the annual Clinical Congress of the ACS, and engagement with other educational media offered by the ACS (eg, palliative care topics included in the Surgical Self-Assessment Program—SESAP). Two major publications emerged from the efforts of the taskforce. In 2009 (with support from the Cunniff-Dixon Foundation), the ACS Division of Education published Surgical Palliative Care: A Resident’s Guide. A decade later in 2019 (after the taskforce had further evolved to become the ACS Committee on Surgical Palliative Care), a textbook: Surgical Palliative Care, edited by Dr. Anne Mosenthal and Dr. Geoffrey Dunn was published by Oxford University Press.

Beyond its prodigious efforts in educating surgeons about palliative care, the ACS Committee on Surgical Palliative Care, especially through its leadership by Dr. Geoffrey Dunn and Dr. Anne Mosenthal, began to change not only the culture and practice of surgery but also medicine in general. In 2012, a new palliative care standard was added to the Commission on Cancer’s standards by which cancer centers are accredited. For the first time, “the availability of palliative care services” was recognized as an “essential component of cancer care, beginning at the time of diagnosis and being ‘continuously available’ throughout treatment, surveillance, and, when applicable, during bereavement.” ⁸

By bringing together surgeons from various subspecialties with shared interests in palliative care, the Committee has also encouraged clinical research ⁹ in the field as well as building robust advocacy for surgical palliative care training within the broader palliative care and surgical communities. Dr. Lauren Wancata became the first postgraduate surgical trainee to receive fellowship training in hospice and palliative medicine (2015-2016) during general surgical residency at the University of Michigan (2011-2018), making subspecialty training in palliative care more accessible to surgeons-in-training. ¹⁰ It is very encouraging to see that other surgical trainees are following in Dr. Wancata’s footsteps. Dr. Heather Logghe who as of this writing is pursuing a hospice and palliative medicine fellowship during her surgical residency, speaks eloquently regarding the wedding of surgical practice with palliative care. “Training in palliative care will provide me the tools I need to palliate my patients both before surgery, and after. . . . As a future trauma and critical care surgeon it is an unachievable goal to cure every disease or traumatic injury; my goal as a surgeon is to heal patients and their loved ones, in life as well as death.” ¹¹

Another member of the ACS Committee on Surgical Palliative Care, Dr. Bridget Fahy, a surgical oncologist and palliative care specialist, was appointed for a 6-year term as a councilor to the American Board of Surgery on July 1, 2022. ¹² Surgical palliative care now has an effective and committed advocate in the person of Dr. Fahy at the American Board of Surgery who will bring this additional perspective to defining the knowledge and skills required for the next generation of surgeons.

Perhaps, the most important product of the ACS Committee on Surgical Palliative Care has been an outcome that could eventually make its role increasingly redundant—a fond historical footnote for a much larger, enduring phenomenon. A cherished goal from the beginning has been the hope that the Committee’s activities would generate enough interest outside of its original membership that might someday give birth to a society devoted to surgical palliative care, expanding the horizons of palliative care within the world of surgery to embrace all the disciplines involved in care of seriously ill surgical patients. And now this essay celebrates that creation with the inaugural meeting of the Surgical Palliative Care Society!

The origin of the society, which will likely acquire legendary features with the passage of time, came about during the shared fellowship of a meal at the ACS Clinical Congress in 2019. In remembering that encounter, it was noted how important Dr. Ronald Maier’s support and encouragement as past president of the American College of Surgeons was to the founding of the Surgical Palliative Care Society. In a dinner together with Dr. Melissa (Red) Hoffman, Dr. Pringl Miller, and Dr. Buddy Marterre at the end of the ACS Clinical Congress in October 2019, rather than describing Acute Care Surgery as a three-legged stool consisting of emergency general surgery, trauma, and surgical critical care, Dr. Maier insisted on a different metaphor—that Acute Care Surgery is more akin to a chair with the fourth leg being surgical palliative care. ¹³

The three founders, Drs. Hoffman, Miller, and Marterre, while sharing a common vision regarding the need to fully incorporate palliative care into surgical practice, have brought together their own unique perspectives of suffering acquired through lives lived inside and outside their profession. As hospice and palliative medicine specialists, they are fully cognizant that one’s entire life experience has profound relevance to the holistic care embodied by their specialty—nothing is wasted. The structure of this new society speaks volumes about the vision of the founders and their collegial commitment to a professional organization that is nonhierarchical, informed by the interdisciplinary team model of hospice and palliative care. Dr. Marterre, an enthusiastic beekeeper, has likened the society’s operational structure to the cooperative relationships between honeybees—“swarm intelligence and cooperative behaviors that prioritize the needs of the hive” ¹⁴ —rather than the traditional hierarchical model of most human organizations. “It turns out, if done correctly, this structure is more efficient than a hierarchical one and builds on the principles inherent to palliative care—empathy, active listening, and collective decision making.” ¹⁵

From the tremendous support and encouragement of Dr. Olga Jonasson (who in its earliest years helped the workgroup/taskforce find its way within the American College of Surgeons) to the dedicated work of so many others, it is no exaggeration to say that Surgical Palliative Care would not have developed so rapidly or with such depth and breadth without the women pioneers who now greatly outnumber the men in the movement. Without the larger demographic shift in which more than half of medical school classes are now composed of women, it is difficult to imagine such a rapid cultural shift happening, especially within surgery. Among all the positive effects of a more balanced demographic in the profession, this transformation of surgical culture which is only now beginning to be manifest will be an enduring legacy of compassion bequeathed to our patients.