Sawubona reprise: reflections on the European Society of Thoracic Surgeons Presidential Address 2022
Editorial Commentary

Sawubona reprise: reflections on the European Society of Thoracic Surgeons Presidential Address 2022

Alessandro Brunelli1^, Amerikos Argyriou2, Hasan Batirel3, Yolonda Colson4, Gail Darling5, Felix Fernandez6, Michael Gooseman7, Toni Lerut8, Daniela Molena9, Nuria Novoa10, Isabelle Opitz11, Kostas Papagiannopoulos1, G. Alexander Patterson12, Rene H. Petersen13, Janette Rawlinson14, Gaetano Rocco9, Brendon M. Stiles15, Javeria Tariq16, Gonzalo Varela17

1Department of Thoracic Surgery, St. James’s University Hospital, Leeds, UK; 2Department of Cardiothoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK; 3Department of Thoracic Surgery, Biruni University School of Medicine, Istanbul, Turkey; 4Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA; 5Department of Surgery Dalhousie University, Halifax, Canada; 6Section of Thoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA; 7Department of Thoracic Surgery, Hull University Teaching Hospitals and Hull York Medical School, University of Hull, Hull, UK; 8Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; 9Thoracic Service-Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 10Department of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain; 11Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland; 12Division of Cardiothoracic Surgery, Washington University School, St. Louis, MO, USA; 13Department of Thoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; 14European Lung Foundation Lung Cancer Patient Advisory Group, Sheffield, UK; 15Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY, USA; 16Leeds School of Medicine, University of Leeds, Leeds, UK; 17Institute for Biomedical Research of Salamanca (IBSAL) Salamanca, Salamanca, Spain

^ORCID: 0000-0002-6505-1656.

Correspondence to: Alessandro Brunelli. Department of Thoracic Surgery, St. James’s University Hospital, Leeds, UK. Email:

Keywords: Empathy; connection; vulnerability; patients; thoracic surgery; lung cancer

Submitted Nov 01, 2022. Accepted for publication Dec 07, 2022. Published online Dec 21 2022.

doi: 10.21037/jtd-22-1550

Introduction from Alex Brunelli (ESTS President 2021–2022)

On the 20th June 2022 I had the privilege of a lifetime to deliver the Presidential Address at the 30th ESTS Annual Meeting (1). Despite it took me nearly two years to conceive and prepare the talk, I never had any doubt on the choice of the topic because this represents very well the core of our profession: connecting with the suffering person in front of us and trying to help them navigating through their most vulnerable time in life.

The following is the link to the recording of the talk:

I had the distinct privilege and pleasure of having many friends and esteemed colleagues in the Auditorium attending the lecture.

I will be forever grateful to them for their enthusiastic response to contribute with their thoughts and reflections. I am convinced their words will highlight even more the importance of teaching and practicing empathy at all levels in our profession and life.

Amerikos Argyriou (Last Year Medical Student 2022, SCTS INSINC)

As a UK medical student chairing the SCTS student committee, it was a great pleasure and privilege to have been invited by Mr. Brunelli to attend the ESTS conference this year. The opportunity to meet surgeons from all over Europe and partake in hearing of the latest research being presented was a truly invaluable opportunity as an aspiring thoracic surgeon.

Mr. Brunelli’s Presidential address did not focus on complex statistics and current surgical outcomes but on the empathetic side of thoracic surgery. Emotional connection and empathy are some of the first things we learn about in medical school, therefore hearing Mr. Brunelli on stage at this point in his career focusing on this sometimes-overlooked aspect of patient care was incredibly refreshing and moving. To myself, his words reverberated a clear message that thoracic surgeons have the privilege of being able to lessen the pain and suffering of their patients, and that this privilege does not only apply in theatre but also in every consultation they have. During his address, Mr. Brunelli displayed a recorded consultation where he tactfully addressed patient concerns and more importantly instilled hope and the message that “we are going to tackle this together,” epitomizing the true spirit of Sawubona.

It wasn’t until the coming days that I realized the real reasoning behind my incredibly positive experience in the Hague. As medical students we are often “not seen” by senior surgeons, but during ESTS the spirit of Sawubona also extended to every Conference attendee. I had discussions with surgeons from all countries who valued me and offered me their time seamlessly. My favorite ESTS memory was sharing and laughing over intimate tales of being a medical student in a small group containing no fewer than 3 past ESTS Presidents.

Hasan Batirel (ESTS Secretary General 2022)

“Sikhona” for “Sawubona”

The Presidential Address is one of the most important sessions of an Annual Meeting. It is a time when all members listen to the experiences and thoughts of a colleague who has deserved to become the President of ESTS. Presidential Address by my friend Alex Brunelli during the 30th ESTS Meeting on the 20th of June 2022 in the Hague, Netherlands can be portrayed as inspirational and exceptional. He gave a clear, fluent, impromptu speech, engaging everyone in a difficult and often neglected topic. Sawubona “I see you” in Zulu language, was very well chosen, as it shows that in all the societies of the world, without any distinction in terms of populace, societal development or language sophistication, connection/empathy is valued and expressed in a uniformly human way. Alex enriched his speech with scientific studies, especially how empathy and human connection/trust mattered! Most of our colleagues would think empathy and connection is innate and can’t be taught. This is not true. We are seeking role models from the very early years of our medical education. A good clinician would immediately be appreciated for his/her extraordinary connection with the patient. Something different, an aura will be sensed around him/her. Medical students, residents, junior attendings will compete to observe or be around such a clinician. Alex’s speech made us to remember those special mentors and that they were invaluable. He reminded us that accompanying someone during a tough journey of thoracic surgical procedure, is not only removing a piece of lung. This journey means sitting side by side, holding hands, tapping on the shoulder, talking, sometimes just seeing each other without any conversation. Humans hate to be alone in tough times, and Alex elaborately showed us how to leave that loneliness aside. We would like to reply to Alex’s “Sawubona” with “Sikhona”.

Yolonda Colson (AATS President 2022–2023)

The presidential address of Mr. Alessandro Brunelli, titled “Sawubona: bridging emotional and cognitive gaps through perspective taking”, highlighted what, in my opinion, is the “soul” of surgery. If the technical aspects of a case are “what” we do, Sawubona is the “why”. Sawubona is a common Zulu greeting meaning “I see you, you are important to me and I value you”. Mr. Brunelli examined the power of this greeting in the context of the thoracic surgeon. He specifically focused on the doctor-patient relationship in such challenging care scenarios as lung cancer, where Sawubona translates to “I empathize, I feel with you, and I can hear you without judgement and from your perspective”. What a powerful statement. Different than sympathy where we feel sorry for someone “over there”, empathy is that vulnerable position of sitting with someone “where they are at” and providing a compassionate response. Cognition is about collecting and processing facts and data but emotional connection between patient and doctor supplies critical input as to risk prediction, clinical outcomes, and most importantly, respect for each patient’s autonomy for their life going forward. It is about caring deeply for the whole patient and allowing oneself to “take off the armor” of the resoundingly confident, always in control, never ever give up surgeon we are all expected to be and open up the space in the consultation to listen to what matters to the patient and to truly serve the whole person in front of you. A timely reminder to all physicians and surgeons taking care of patients.

Gail Darling (President of the Canadian Association for Thoracic Surgery 2022)

Mr. Brunelli delivered a powerful message to members of the ESTS in his presidential address in The Hague at ESTS 2022. He challenged us to have the courage to be imperfect, to be vulnerable, to be authentic and in so doing to connect with our patients. He challenged us to demonstrate compassion and empathy.

The title of his address was “Sawubona” a greeting, which means: I see you, I acknowledge you, I accept you. The message of Sawubona resonates. It is the essence of an authentic interaction between two human beings whether doctor and patient, doctor and allied health professional or family members. Mr. Brunelli asks us to be present, to listen and be sensitive to patient cues.

We talk about empathy and compassion, but do we really understand what these really mean? Mr. Brunelli explained these concepts and why they are so important to the doctor patient relationship. They are the foundation of trust. Trust is essential to the relationship between a surgeon and their patient. When a patient consents to an operation, they are putting their trust in us to look after them, to do our best, far beyond the words on the form or a list of potential complications.

Empathy is active. It means we see the perspective of the other person, we don’t judge, we understand and share the feelings of the other person. Compassion is not possible without empathy but takes it further. Compassion motivates people to help, to relieve suffering.

In his challenge to us, to accept ourselves as imperfect, to be vulnerable, Mr. Brunelli also asked us to be kind to ourselves first, to have compassion to ourselves. Without self-compassion, we wear an impenetrable armour and cannot connect with the patient.

Felix Fernandez (Chair of the STS Workforce on National Databases)

I had the distinct pleasure to hear in person the moving Presidential address “Sawubona” delivered by the incomparable Dr. Alessandro Brunelli at 30th Annual Meeting of The European Society of Thoracic Surgeons. Sawubona, or “I see you”, to me defines the highest echelon of our practice as Thoracic Surgeons. For me, in this context, Sawubona means understanding our patients, meeting them where they are as individuals, and applying our specialized craft in a manner that is specific to their unique goals and values. Sawubona changes the entire paradigm through which we view patients. They are no longer defined by risk-adjusted mortality rates or cancer-specific survival. Rather they are viewed as individuals with hopes and fears in whom success is best measured by the value added to their quality of life, which is defined differently for each patient. Such an empathic approach allows us as Thoracic Surgeons to have a more profound connection with and, therefore, impact on our patients. I also believe Sawubona elevates the surgeon as well. It gives deeper meaning to our work, lifts us spiritually and brings a greater sense of fulfillment. As I listened to Dr. Brunelli deliver his address, I was filled with emotion. I reflected on opportunities I have to impact patients in a more meaningful way. This message clearly is broadly applicable across all of life, and I further reflected on instances in which Sawubona has greatly enriched my life as well as when it was missing. With tears beginning to well in my eyes, I left with the inspiration to be not only a better surgeon but a better person. I thank my friend Dr. Brunelli for sharing with us the most unique and inspirational Presidential address I have ever had the privilege of hearing. Dr. Brunelli, I see you.

Michael Gooseman [ESTS Early Career Member Lead 2022]

As thoracic surgeons we are well drilled in the guidelines and algorithms that are known to help in the selection of patients for surgery. We always strive for technical excellence and fully acknowledge that an operation performed meticulously will benefit our patients. The post-operative care is carefully directed to the physiological requirements of each patient. Essentially, the whole peri-operative pathway from patient referral to successful discharge is well described and practiced in a very clinical manner. Surgical success is quantified in terms of early removal of chest drains, early post-operative discharge and lack of complications. We find success in performing surgery through less invasive approaches using newer technology or more demanding surgery such as complex segmentectomies.

Of course, many of the markers that surgeons see as a success, will also be shared by the patient. Smaller incisions that allow earlier discharge from hospital or preservation of lung parenchyma that has less impact on breathing will be hugely appreciated. However, we must remind ourselves as the Presidential address did, that the demonstration of emotional understanding is absolutely critical to each patient. Surgical centres pride themselves on volume and indeed this has often been shown to be an indicator of quality. However, it must be remembered that for each individual patient the surgical journey is a deeply personal moment in their lives with often life changing implications. This should be reflected in the approach we take, as the address said, from the moment the patient enters the consultation room. Sawubona—we see you. The simple but profound act of looking a patient in their eyes, acknowledging them as an individual is as important as anything else we will do in caring for our patients and should be something that is embraced and never neglected.

Toni Lerut (ESTS President 1999–2000)

Alex Brunelli treated the audience with his inspired and passionate Presidential address. The eye-catcher in the title of his address is Sawubona, a South African Zulu language expression, that literally means: I see you, you are important to me and I respect you.

In other words, it gives the interlocutor the feeling to be valued and respected, a feeling of empathy.

Empathy, the key word in his address, is the ability to feel as doctor the patient’s emotions and to respond effectively with compassion.

This attitude of empathy expressed by the doctor’s body language, by the direct eye contact is fundamental to build a bond of trust between doctor and patient.

When the doctor puts off his/her emotional harness and shows his/her own emotional vulnerability, with openness to empathic response as an essential component, the patient will feel more confident to express what he/she really feels.

Brunelli stated that competence if supported by this mutual based empathy and the resulting trust, not surprisingly, has shown to improve outcome.

Why do I find Brunelli’s Presidential address so timely, so important?

In our technology, IT dominated working environment therapeutic decisions are made in multidisciplinary meeting rooms—since COVID-19 increasingly held online—even without having seen the patient.

In outpatient clinics I observe a growing tendency of a doctor sitting behind a desk facing a PC screen, a barrier separating patient and doctor.

The latter showing little body language and no eye contact strumming on his pc keyboard while taking the patient’s medical history.

Brunelli’s Presidential address is a plea for “le colloque singulier” that unique moment between patient and doctor in an eye-to-eye conversation so fundamental in establishing the so essential confidence, trust.

This remains the basis, the key of our profession in particular the surgical profession.

Sawubona as a metaphor for bridging emotional and cognitive gaps through perspective taking is a theme that should be part of the attainment targets in the curriculum of every student in medicine.

Daniela Molena (AATS Chair of the Thoracic Education Committee 2022 and Vice-President of Women in Thoracic Surgery 2022)

Healing from the coronavirus disease 2019 (COVID-19) pandemic by taking the “mask” off and connecting

The powerful presidential address titled “Sawubona: Bridging Emotional and Cognitive Gaps Through Perspective Taking,” given by Alessandro Brunelli at the 30th European Society of Thoracic Surgeons Meeting, in the Hague, Netherlands, on June 20, 2022, was the perfect way to celebrate our finally being together in person after two years of the COVID-19 pandemic. Dr. Brunelli, stripped of his “armor” (to echo the language of University of Houston researcher and author Brené Brown), bravely addressed subjects rarely mentioned at thoracic surgery meetings: empathy, connection, and being present with our patients. He connected with all of us in the audience as he spoke to our core values as surgeons and reminded us of the reason we chose this profession in the first place: improving the lives of our patients.

By dedicating his career to advancing risk assessment for lung surgery, with the goal of controlling the outcomes of an operation, Dr. Brunelli has learned that there is so much about outcomes that is out of our control as physicians. He therefore proposed a new way for physicians and patients to interact—a new world where the principles of care are reversed, where patients and caregivers set the goals and surgeons embrace and seek to fulfill them. This new world is based on true connection and the ability to see each other without “masks”.

After two years of social isolation, upended lives, constraints, and loss of work, purpose, and loved ones, Dr. Brunelli’s message was especially emotional. The pandemic has had unprecedented consequences for the medical community. Rates of burnout and mental health problems among providers, which were already rising before the pandemic, due to increased demands and lower job satisfaction, climbed precipitously during the COVID-19 pandemic and continue to remain high.

I agree with Dr. Brunelli that the way forward in health care is through empathy and connection with our patients, but I would like to add that the same change is needed with each other. Thoracic surgery is a field often defined by perfectionism, strength, and resilience, and little space is given for vulnerability. But as Brené Brown has demonstrated in her research, without vulnerability there is no true connection, and without connection there is no healing. Sitting in the audience with my friends and colleagues, I felt a powerful sense of community. By fostering an atmosphere of belonging, Dr. Brunelli gave me hope that there is a future for thoracic surgery where we recognize and celebrate every person’s worth and dignity, regardless of our differences, and perhaps even because of them.

Nuria Novoa (ESTS Director of Education 2022)

Empathy, professionalism and surgery

Every presidential address is expected with interest because each president has a personal message to communicate. No matter whether it is a recurrent topic or not, all of them have a personal touch that makes them different and special. This year, Dr. Brunelli surprised us with an exciting title: Sawubona. What does it mean? Sawubona is a Zulu greeting that means empathy. A human dimension in the doctor-patient relationship. The topic is very relevant: empathy is a basic characteristic of our professionalism. In this time when medicine has moved toward an evidence-based technical profession, when we are no longer the artist-doctor that we used to be, we need to go back and include more humanity in our daily work. This is an especially remarkable message coming from Dr. Brunelli, a surgeon who has taught us working with data, constructing databases and risk scores, to foresee and avoid unnecessary risks to patients. In his latest speech as president, he moved to a more humanistic and emotional presidential address. Not only discussed the problem, but also brought good news: empathy can be learned. Simple acts, like showing value and respect and spending adequate time to each patient, are basic actions to improve our doctor-patient relationship. We should not forget that presence or lack of empathy can change the perception of the patient about his/her doctor, influencing positively or negatively his final opinion about the professional capacity of the person that will operate on them. But it also will influence the outcome of the treatment. Dr. Brunelli’s legacy is very positive and hopefully long-lasting.

Isabelle Opitz (ESTS President 2022–2023)

Sawubona—“I see you, you are important to me!”

“What an extraordinary Presidential Address”, were my very initial feelings still being myself very emotional about the honor to introduce our 30th ESTS president and my friend Dr. Alessandro Brunelli. So personally, I was primed and in the perfect mindset for such a “non-traditional” and emotional speech! My second association was “What a great choice!”—Why? Because the choice of the topic for a presidential address is not only important because it is reflective for the “president’s personality”, to my opinion it is even more important because a large proportion of the audience consists of our next generation Thoracic Surgeons. Therefore, the choice is influencing the future of our field and needs to be carefully chosen—in this respect, the choice could not have been better!

In a world increasingly transforming any communication into digital exchanges—even more after the pandemic—“SEEING” your counterpart is unfortunately no longer natural or cannot be taken for granted. This is particularly tragic for our patients, who are desperately depending on our empathy and sensitive communication in situations, which are in nearly 100% difficult—such as delivering the message of the diagnosis of cancer, to mention only one. However, I do not want to adapt the streamline of blaming only generation Z being accused to be “Instagram, TikTok, social media driven”, this is actually equally a message to our generation!

The presentation and in particular the video reminded me one more time—and cannot be often enough—that every patient deserves our full attention in all kind of encounter: outpatient clinic, pre-/postoperative visits etc. No quick glimpse on the phone, computer desktop, watch or whatsoever should distract us from actually “seeing” our patient in the eyes and herewith opening the window to our personality as well giving him or her the feeling of dedicating the full moment and all our expertise and empathy to his or her particular special condition. What I am telling myself every time I am entering the room to see a patient to memorize like a mantra “For you it’s the same text like maybe even 10minutes ago, for this patient it is the very first time and maybe life changing moment”! Thank you, Mr. President, Alex, for reminding myself and our ESTS community of this important aspect of our professional life in a very authentic and typical for you presidential address!

Kostas Papagiannopoulos (ESTS President 2017–2018)

SAWUBONA; “I see you”. Alex Brunelli, the 30th President of ESTS challenges us about the diachronic need of the doctor who must remain connected with patients and those who love and care for them.

Our science, as every other, is swamped with technology, assisted by artificial Intelligence and demands technocrats and techno gigs to treat patients.

But how real is the risk that the modern Thoracic surgeon, the “Robosurgeon”, who operates in front of a console, far from his/her patient will become distant and “disconnected”?

How real is the risk that the perfect scientist will stop “feeling” the needs of a patient? And how important such connection must remain in order to heal a patient?

The recent COVID pandemic showed clearly why humans need to remain connected. And it is not their primate needs that have to be satisfied but rather their need to be emotionally secure and connected with empathy, considered, respected and protected with an aura of good feelings; a touch that allows good energy to flow between themselves and those who are responsible for their treatment.

And without doubt they do not need necessarily a leader or a mastermind to decide for them. They demand someone who will listen and not simply hear, the doctor who will assist them to pace themselves through the difficult journey of surgical treatment and recovery, the one who stands by them and equips them with a daily smile, a positive thought and the drive to come through the life-threatening experience of complex surgery.

Sawubona, “I see you”. Do I really do that? This is the doctor we need to embrace, the scientist we need to educate and the thoracic surgeon we, as teachers, need to demand and train in order to secure a dignified treatment for our patients.

G. Alexander Patterson (AATS President 2009–2010 and Editor in Chief JTCVS)

It was my great honor to be in the audience during Professor Brunelli’s Presidential address at the 2022 Annual meeting of the European Society of Thoracic Surgeons. During my 40 years as a practicing academic thoracic surgeon, I have heard and read many lectures by the esteemed leaders of our international cardiothoracic organizations. I sincerely believe that Alex’ presentation was among the most impactful. Delivered without notes or podium, he engaged the audience with powerful concepts so important for the development of the patient-surgeon relationship. Empathy, self-awareness, perspective-taking and eye contact were among the profound elements he discussed in eloquent fashion.

Alex discussed the Zulu greeting Sawubona; “I see you”. He described how critically important this attitude and perspective is for the creation of a positive patient-physician relationship. As surgeons, this is clearly the most important relationship. It has a direct impact on the patient experience and outcome.

While the patient-physician relationship is pre-eminent, the message of Sawubona is so important in all of our professional and personal interactions. This is why I believe Professor Brunelli’s address has such impact. What we do as thoracic surgeons is complex. We cannot do it alone. Most of us work in academic environments and are engaged with large teams in various environments; office, clinic, operating room, intensive care unit and research laboratory. We need to promote the concept of “I see you” in all our teams. Our trainees, students, colleagues, nurses and staff need to be absolutely certain that we “see” them. Everyone is entitled to a sense of psychological safety in their workplace. The concepts of empathy, self-awareness and perspective taking are critical elements of psychological safety. It has been well documented that better outcomes in complex organizations, especially health care, are achieved in a culture of psychological safety.

We all have an obligation to seriously consider and adopt in our daily interactions with our patients and teams the mindful practices Alex demonstrated so beautifully. These are not warm and fuzzy abstractions for the expert surgeon with little time. These are crucially important learned behaviors that impact not only patient outcome, but every aspect of what we do as thoracic surgeons.

Rene H. Petersen (Director of the ESTS Annual Meeting 2022)

Alex Brunelli addressed a very important, however difficult topic in his Presidential Address at the 30. ESTS meeting in the Hague, namely the interpersonal relationship between surgeon and patient. Our field is evolving rapidly and new treatment strategies involving among others immunotherapy are expected to increase the survival for lung cancer patients. However, it is so important, that we as surgeons embrace our patients and involve them in the decision making. Many of our patients are old and frail and should not necessarily have the standard therapy, that we offer for the majority. Individual treatment strategies based on a shared decision making is important. Balancing the potential benefits of surgery versus the operative risk can be a difficult decision, where the patient knows best, however based on thorough information from the surgeon. When communicating with patients Alex Brunelli stressed the importance of meeting the patient at the same level, this means sitting in front of the patient or on a chair next to the bed, so that you can look your patient in the eyes. Crossing arms and legs should be avoided in order signal an open mind with your body language. The voice should be calm and warm using open questions, that often gives patients the best opportunity to express their emotions and concerns. Empathy is a very important skill for any physician and is essential in caring, especially in very ill or dying patients. One challenge for many surgeons is to embrace complications and maybe the loss of your patient. Many emotions are at play, and often you consider, what you could have done to avoid this situation. In my experience honesty is key, letting patients know what happened and what could have been improved, despite the best intentions, is very beneficial for the interpersonal relationship.

Janette Rawlinson (ELF Lung Cancer patient advisory Group, EORTC patient panel 2022)

This dedicated, experienced surgeon shares his wisdom on empathy in patient communication, evidencing feelings and thoughts many lung cancer patients experience.

The need to be authentic, humble, an active listener, fully present, open stance, not hiding behind a desk nor talking down to a ward patient, honouring the patient without distraction revealed a sensitive and caring professional.

Acknowledging many patients gloss over issues with a doctor versus greater openness with a nurse, he expressed sadness patients felt unable to fully describe situations. This is often unrelated to the professional but lifetime NHS messaging not to trouble a doctor with minor ailments which works against lung cancer—less of an issue in other cancers or healthcare systems. Others may ‘gatekeep’ a surgeon, consultant or doctor leading patients to conclude clinician aloofness or arrogance are the cause.

Eloquently recognising stigma, shame and disbelief patients have with elevated anxiety validates what many feel. Recognising that, irrespective of education, scientific or medical knowledge, synthesising complex information at an extremely vulnerable time, facing a life changing diagnosis, patients may need additional support

Sharing parts of ourselves creates rapport. Improved empathy takes courage and humility. Not all are ready—but improving trust and belief improves patient experience.

Zulu terms ‘sawubona’ and ‘sikhona’ explained how to see the whole person not a clinical case, cells, images or number.

Delivering his address with passion, humility and insight gently persuading others what matters to patients might differ from clinical measures, revealed heartfelt wisdom. Peppered with examples, anecdotes, videos, images and inimitable passionate delivery understanding the patient perspective, this should be compulsory viewing for all healthcare professionals not only surgeons.

Gaetano Rocco (ESTS President 2007–2008)


Dr. Brunelli’s Presidential Address (let’s call it “Sawubona”) has a powerful insight into the future of patient-surgeon relationship while recalling a nostalgic flavor for the time-honored approach to medicine. Sawubona contains reminders of old painting showing the incessant care of a doctor after a long overnight wake of a sick child, as well as of legendary tales of a traveling physician in most remote rural areas with dust and sun as the only company. Sawubona refers to the emotional armamentarium deeply hidden into the physician that makes a good doctor an extraordinary human being. From Hippocrates to genomics, Sawubona summarizes the wavelength we all tune in to provide the first healing step for our patients, personally, eye-to-eye.

Brendon Stiles (Chair Lung Cancer Research Foundation 2017–2021)

The right message for our time

I have had the great fortune to sit through many presidential addresses at academic cardiothoracic surgical meetings. Although each speech is unique in its own right, each often follows a similar formula. Few presidential addresses are what I would call “selfless”—indeed the forum is not contrived to be a moment to bring the needs and wishes of others to the forefront, but rather a time for self-reflection.

However, Alessandro Brunelli’s Presidential Address at the 30th annual European Society of Thoracic Surgery turned the formulaic approach on its head and was instead a call for humility, vulnerability, and empathy on the part of surgeons. Dr. Brunelli’s talk was titled “Sawubona: bridging emotional and cognitive gaps through perspective taking”. For those who don’t know of Sawubona, it is an ancient Zulu greeting that literally means “I see you”. But Sawubona is not simply a superficial “hi” or “hello”. Rather, Sawubona suggests a recognition of the worth and dignity of the person in front of you, a moment of actual connection.

Dr. Brunelli gave a remarkable and provocative address. Surgeons must be good human beings. We must demonstrate competence, but also warmth and an ability to bridge the emotional gaps inherent in today’s world to optimize our outcomes, as well as to overcome patients’ fear and anxiety. Truly “seeing” our patients in this manner will allow us to connect emotionally with our patients, will allow us to better estimate patient risks and preferences, and will likely affect outcomes including complications, length of stay, and readmission rates. In our busy world it is easy to undertake “patient encounters” with little emotional expenditure. However, we must remember that for each cancer patient, their first visit with their surgeon is perhaps the most important moment of their day, week, or even their life. We must see and recognize the person inside the patient. Thank you Dr. Brunelli for reminding us of “Sawubona”.

Javeria Tariq (Last Year Medical Student 2022-Society for Cardiothoracic Surgery in Great Britain and Ireland INSINC Committee)

My first experience of thoracic disease beyond textbooks was in theatre with Dr. Brunelli as operating surgeon. Since this encounter, he has been an exceptional mentor taking every opportunity to teach not only in the spirit of sharing knowledge but imparting wisdom to the next generation. I have always been struck by his humility and way with patients. So, attending the 30th ESTS meeting as the president’s guest was indeed a career-defining experience and his address was a genuine representation of his ethos.

As a medical student, I am regularly coached during patient encounters to “display empathy” with limited appreciation of what the word truly means. The presidential address offered me a fresh perspective on compassionate healthcare through the practical application of empathy.

I learnt how synchrony between non-verbal and verbal communication consolidates the very messages we want to convey. And so, I found myself engrossed in taking notes so I could mirror similar techniques within my practice. What’s more, I felt empowered that these skills could be easily integrated not only into clinical practice but into everyday human interaction.

I was particularly moved by the transformation in patient satisfaction by what seemed to be feasible, small changes that we could all adopt whilst delivering care. The patient was now not a 16 mm × 4 mm NSCLC segmentectomy but a man with three grandchildren who feared falling asleep as he believed his cancer could kill him. Dr. Brunelli’s approach allowed the patient to feel truly seen even in his most vulnerable state. Allowing a special relationship to be formed, one of transparency and trust.

I am greatly honoured to have had the Sawubona message delivered to me first-hand at a junior stage in my career, as I am certain it will shape me into the person I aspire to be. Surgeon and humanitarian.

Gonzalo Varela (ESTS President 2015–2016)

Look at the eyes of your patient

A few months ago, my wife was suffering a mild health problem and I accompanied her to a doctor’s office. The colleague spent about ten minutes on the anamnesis, and all along that time he eagerly typed on a noisy keyboard, recording data in the hospital’s electronic databases. He’s sight was alternated from the keyboard to the computer screen. I don’t remember him ever looking at my wife in the eyes. After consultation, she whispered to me: “I don’t believe he can remember my face”.

Eye contact is just one of the components of non-verbal communication, and it is considered one of the relevant attitudes of empathic clinical behaviour (1). Empathy is paramount in the physician-patient relationship and has a positive impact on health outcomes explained by specific neurobiological mechanisms (2,3).

This year’s Presidential address at the 30th European Conference on General Thoracic Surgery by the European Society of Thoracic Surgeons president, Alessandro Brunelli (1), included a curious word in the title: “Sawubona” a Zulu greeting that can be translated as “We see each other, we acknowledge each other, we recognize each other” (4). Sawubona is about caring, about a warmth relationship, about doing what the patient matters. Sawubona is empathy, and empathy is understanding and sharing the feelings of our patient. It is a fundamental component of the doctor-patient relationship, creating a link between you and your patient because he or she knows that you care.

We, surgeons, have currently focused trainees’ education on surgical techniques and technology, outcomes, and cost-containment. Unfortunately, teaching empathic attitudes towards patients is not included in most training programs in surgery. A randomized controlled trial by Riess et al. (5) has shown that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.

I’d like to thank Dr. Brunelli for bringing to our minds again the relevance of “never underestimate the power of our verbal and non-verbal communication, especially when addressed to emotionally vulnerable patients” (1).


Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at AB serves as an unpaid Associate Editor-in-Chief of Journal of Thoracic Disease and is President of ESTS 2022. AB received consulting fees and honoraria for lectures from Astra Zeneca, Roche and Ethicon. HB received honoraria for lectures from Johnson and Johnson, Astra Zeneca, and payment for expert testimony from Johnson and Johnson. DM serves on a steering committee for AstraZeneca and as a consultant for Johnson & Johnson, Bristol Myers Squibb, Merck, and Genentech. IO reports that no real conflicts of interest are related to the work. The following could be perceived as such: Roche (Institutional Grant and Speakers Bureau), AstraZeneca (Advisory Board and Speakers Bureau), MSD (Advisory Board), BMS (Advisory Board), Medtronic (Institutional Grant), Intuitive (Proctorship). KP serves as an unpaid Editorial Board Member of Journal of Thoracic Disease. RHP serves as an unpaid Editorial Board Member of Journal of Thoracic Disease and is a member of the advisory board for AstraZeneca, Roche, MSD. RHP received speaker fee from Medtronic, AMBU, Medela, AstraZeneca. JR reports that she is involved with a number of lung cancer groups, charities and organisations in UK and Europe, as a patient partner in research/public patient partner voice. She holds no leadership roles e.g., Chair. The Patient public voice role is an equal member in the duties and responsibilities of those committees. All have policies of reimbursing travel/accommodation to ensure that nobody is left out of pocket by taking part in research. Some offer honoraria. Very few meetings have taken place in person during the pandemic in person therefore travel reimbursement has been minimal. Her CCG role was a fiduciary role as an equal member of the board. As an independent, she is repaid as an individual. GR received royalties from Scanlan International and he is a member of the advisory board for AstraZeneca. BMS received grants from Bristol Myers Squibb and Bristol Myers Squibb Foundation, and consulting fees from Pfizer, AstraZeneca, Bristol Myers Squibb, Roche-Genentech, Arcus Biosciences, Galvanize Therapeutics, Medtronic. BMS is the inventor of patents TARGETING ART1 FOR CANCER IMMUNOTHERAPY (Patent Application Serial No. 63/307,502, filed February 7, 2022). BMS is a member of the Steering Committee for Medtronic for Medtronic, Data Safety Monitoring Board for Galvanize Therapeutics, Trial Steering Committee/Data Monitoring and Ethics Committee for RAMON study, Scientific Advisory Board for LUNGevity, Board and Vice Chair for Lung Cancer Research Foundation. BMS’s spouse receives personal fees for salary from Xalud Therapeutics and owns stock, and options in Xalud Therapeutics, and stock in Pfizer. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


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Cite this article as: Brunelli A, Argyriou A, Batirel H, Colson Y, Darling G, Fernandez F, Gooseman M, Lerut T, Molena D, Novoa N, Opitz I, Papagiannopoulos K, Patterson GA, Petersen RH, Rawlinson J, Rocco G, Stiles BM, Tariq J, Varela G. Sawubona reprise: reflections on the European Society of Thoracic Surgeons Presidential Address 2022. J Thorac Dis 2023;15(1):204-213. doi: 10.21037/jtd-22-1550

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