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RESEARCH
PRESIDENTIAL United
ADDRESS
We Stand, HIRAM
Divided
We . . . .’
C. POLK, JR., M.D.
Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky 40201 Submitted for publication December I. 1975
I come before you today with the deepest appreciation to discharge the penultimate responsibility of the Presidency of our Association. On such an occasion, three statements are commonly made. The first relates to the honor for the opportunity; the second may well be a conscientious review of the spoken words of all prior presidents; the third implies an unending concern as to the nature and subject of this address. I begin by denying all of these tenets. The honor involved is better expressed as gratification for working at a variety of responsibilities as this Association grew into a significant influence in American surgery and as an expanding one in the broader senseof academic and medical life. I specifically avoid the review of remarks of my predecessors at times such as these for fear that all the incisive ideas would be disclosed to have been theirs and the less judicious ones mine. The choice of a subject for this occasion concerned me only slightly, for I was certain that some circumstance would disclose a common thread for matters of concern to the Association and bring an appropriate response to mind. The tragic accuracy of that premonition was reflected in the evening hours of June 24 when I learned of the death of our colleague and my close friend, Ted Drapanas. In the many days of genuine good times and serious concern we spent together, there was no principle which was more consistently considered for our deliberations ‘The Presidential Address presented to the Ninth Annual Meeting of the Association for Academic Surgery, Minneapolis, Minnesota, November 13-15, 1975.
than that which I share with you today. That principle is a relatively simple and solitary approach to many of our present problems and one with which this Association may be particularly well equipped to deal. Recall, however, Mencken’s statement that for every major problem there is a solution which is simple, direct, and wrong! Further, recall that I come here to review my prejudicial thoughts with you and to convince you that they are valid. I am further ever mindful of the remarks of Medawar [23] who demonstrated the folly of prediction by the remarks of the distinguished surgeon, Lord Moynihan. Undaunted, my proposal is simply that a conscious sense of unity in our affairs and at all our personal and professional interfaces can minimize, palliate, or even cure many of the ills that confront today’s surgical academician. What are the problems that face us? With no primacy of order, one must consider research funding, human experimentation, true disclosure, the antiintellectual populist movement, recertification, professional liability, the number and influence of the size and composition of our undergraduate and postgraduate training programs, the role of minorities with a special concern for our associates, now discriminatingly designated as “FMG’s,” national health insurance, peer review, governmental regulation, and the morality of personal compensation, just to mention a few! What is this unity? Is this the unity of this homogeneousgroup meeting here today? No, I am speaking of unity in the broadest sense:
127 Copyright D 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
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with all our society, with all our colleagues in academic life, with all our colleagues in the biomedical sciences, and most especially among all of us who are privileged to toil as surgeons. Assuming that I can persuade you as to the value of unity, one attitudinal postulate is essential: Before we can take that first step toward it, conscious effort to depersonalize issues is a sine qua non! Not so very long ago, Richard Varco shared with me valuable insight into this requisite when he asked, “Do you notice how often some people try to make their own personal problems great national issues?” If we can rise above this particular hang-up, unity becomes attainable. Why unity? Frequently, the process of common reasoning produces solutions of a broader and firmer nature. Unity allows a concerted response from individuals whose counsel has allowed answers, inevitably providing greater influence: in two words, more clout. To begin to consider the benefits of such unity, one must consider the myriad interfaces of the academic surgeon. SPHERES OF CONTACT In the broadest human sense, the academic surgeon must concern himself with all of society; the ideal unit representing just that is his family and secondary nonprofessional contacts and friends. The family tragedies of many of our colleagues are sufficient to underline how frequently we assign secondary or even tertiary importance to this aspect of our lives. Yet it can be the balance wheel which places many of the other stresses and possible solutions in more appropriate perspective. Of course, the academic surgeon is ever concerned with his patients and with related citizens, now unfortunately depersonalized as consumers. He must also relate to his government and most especially to that arm involved in the health process and the planning thereof and must develop the various interfaces with other health professionals, with hospitals, and most especially with other academicians.
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Now, what are the purely academic interfaces of the Association’s members? Herein, he or she must relate again to his patients and to students and residents. We must relate to a variety of administrative officials, including the chairman of the department, the dean, the vice-president or provost, as the case may be, and, inescapably, hospital administrators. A further relationship essential to our identity is that with our nonsurgical biomedical colleagues. Indeed, Anlyan has succinctly reviewed the contrasting demands involved for the surgical educator and investigator [l]. It is in this particular arena, the intramural one, if you will, that many of the more overt concerns of the members of this Association may be manifested. However, this second sphere of influence inevitably turns to a third: all of medicine as the larger community. This is most clearly reflected in the relationships that one must secure with colleagues in similar disciplines within the locality. This effective liaison must also extend to all the practitioners of medicine and related health professionals with whom one works. Be reminded that the academic surgeon is viewed as a hero when he is more than 100 miles away from home and as the devil himself in his own locale! Beyond all of this is the national dimension of one’s surgical activities, often the pervasive ambition of the younger academic surgeon and the disappointing bane of the senior man who has tasted (or, more appropriately, swallowed) the fruit and found it bitter. Dunphy’s analogy of the jet set professor is both valid and damning [9]. To choose between responsibilities continues to try even the Solomons among us. Indeed, the proliferation of societies and associations speak to a conflicting series of needs [14]. One group is exclusive, the other inclusive. One club tends to attract more senior members while another draws junior participants. One society becomes large, the other seeks to remain small. As one priority is set, the balancing or opposing characteristic appears, almost by sleight of hand.
HIRAM
C. POLK,
JR.: PRESIDENTIAL
EXEMPLIAE GRATIAE Neither time nor common sense allows a point by point discussion of how unity with one’s fellow man, whatever the dimension, is an appropriate response to our concerns. However, it is germane to discuss enough examples to persuade you of the validity of the concept and to stimulate you to develop applications and significance far beyond what I see from my limited vantage point. Let us first consider the intramural interfaces of the academic surgeon. Undergraduate education is where it all begins and ends! Our dean is prone to remind us that we, first and foremost, operate a schoolhouse. The undergraduate medical curriculum appears to be in a process of continual cyclical variation [16], in part because of the inevitable gap between expectation and actual experience [ 151. Indeed, curricular revision does not seem to be able to close this gap. The cycle seemsobligate; only the length and interval seem to vary. However, the dismembered surgical disciplines and the erstwhile department are notoriously ineffective in competing for curricular time. With each passing cycle of curricular revision, the surgical proportion thus becomes increasingly miniscule. This allows even more students, who choose disciplines other than surgical careers, to go forward into their life’s work with an inappropriate understanding of one of the only four therapeutic modalities known to man. Furthermore, it sharply impairs the ability of the department and its divisions to compete for quality students by virtue of exposure alone. Further, consider the relative impact of a unified, intact department of surgery upon discussions with deans and other university and hospital administrative officers. There is no clearer example of the divide-and-conquer concept than the ease with which dismembered departments are managed by administrators at all levels. Without choosing one discipline as an example, consider how much can really go wrong in a three-man division of a 400-member faculty medical school that will get the dean’s consistent at-
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tention. Compare this with the impact that a 3%man department’s support of the position of the three-man division can bring to bear, not only in the dean’s office, but in all the councils of the school of medicine. Not to be overlooked is the benefit of a unified approach to mutual financial, technical, and facility needsinvolved in such a department. Unity’s opposite number is fragmentation. But first, what is there to share between the surgical disciplines? Does the cardiac surgeon have more in common with the modern cardiologist or his present colleague in (general) surgery. Surely he has much in common with both. The individual with insight perceives that he can retain the best of his common ground with the parent surgical discipline and build new and lasting dimensions of common thought and concern with the medical cardiologists. The physicians oriented toward medical and surgical cardiology have requisite awareness of abnormalities of cardiac rhythm and ventricular function curves. Surely these mean most in addition to those which the cardiac surgeon shares with his other surgical colleagues: hemostasis, infection, foreign body failure, and overall supportive care. Beyond common interests, there are the surgical bridgetenders [24], those individuals who develop skills enabling them to evaluate developments in related disciplines and bring them to bear upon the whole spectrum of surgery. Realize how precisely the evaluation of surgical intensive care skills relates to the impact of complicated and precise postoperative study of the cardiac surgical patient. On an even broader plane, the pervading influence of infection and its limitations upon further advances in all the surgical disciplines exemplifies a common ground, requiring judicious input from the so-called basic sciences. In considering further fragmentation in surgery, one may question, as has Orloff [26], that the nominal courtesy of denoting subspecialties as superspecialties went very well until some of those so addressed began to believe all of the connotations therein.
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Further, continued specialization has been associated with identifiable second-generation deterioration of insight and imagination in the discipline. The most pathetic example can be found in the letter quoted, arguing or, rather, demanding, that a division be made a department. Many surgical scholars have long appreciated that general surgery is purely a general education in surgery [25]. Wangensteen, among others, argues convincingly that breadth of understanding is essential to discovery [34], and Eckert further pointed out that advances in most specialties often have been made by the broadly trained surgeon [lo]. Both Varco [33] and Hanlon [17] have asked whether the further specialization of surgery represents professionalism in the highest sense or a misdirected sense of elitism. Does it indeed serve selfish interests or is it for the common good? Where is the tip point, that moment at which conditions change not in degree, but in direction? When does “good” become “bad”? If further specialization continues in an uncoordinated way, excessive fragmentation will surely morsellate all of surgery. The medicolegal complications of further specialization must also be acknowledged. Are our senior, respected, and innovative leaders guilty of overdramatization when they describe such fragmentation as “monsters born while reason sleeps”? Is further specialization in the common interest? Will it not further increase unavailability, increase maldistribution, and surely increase costs? On the other hand, the likelihood of discontinuing a previously identified specialty is surely not great; indeed, it has been likened to the difficulty in relocating the community cemetery. Can we not accept the thesis that the whole of surgery has more in common than it has in discord? The conscientious definition of further specialty development will be a continuing need of our discipline. Turning from consideration of extramural as well as intramural surgical fragmentation, the academic surgeon must look to his relationship with his colleagues within the
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university [36]. Talcott Parsons has pointed out [27] that the professional schools come closest to integration of the university’s social and intellectual responsibilities. Further still, training as specialists in the applied professions is an ultimate application of knowledge for solving problems of high social value but, at the same time, implementing the cognitive resources of the university. Our university citizenship separates us from tradesmanship; we must appreciate that citizenship and the unity with the scholarly community that it implies. We recognize the valuable but innately divisive concept of the change of clothes for the operating room. Moore has pointed out that this alone tends to isolate us, not only from microbial threats but from a frequent and vital interface with our nonsurgical colleagues [25]. Indeed, many respected individuals in medical disciplines have literally not seen an operation in decades, an occurrence within the vividly recent memory of each of us. Surely they should not spend every morning watching the technical feats of operative legerdemain. Nevertheless, are not these physicians obligated to the patient they see tomorrow to be currently aware of both the opportunities and the limitations of modern surgery? Recall a further effect of this same barrier. Our operating room sanctuary competes all too effectively with bedside teaching, a criticism widely leveled at surgery only 10 years ago. Only a major national and sustained local effort succeeded in retaining, in the face of a persistent barrage from other disciplines, our primary role in undergraduate education. Although we must be aware of the difficulties that the nonmedical constituents of the university have in perceiving our problems. our seemingly spendthrift ways, and OUI mirage of wealth, even greater concern must be directed toward the misunderstanding oj surgery and surgeons by other clinical de. partments and their members. Despite the common assumption that departments oj surgery are fiscally well off, are overstaffed and travel excessively while leaving all the
HIRAM
C. POLK,
JR.: PRESIDENTIAL
work to the residents, Orloff found that, by comparison with other clinical departments, surgical departments are traditionally underfinanced, particularly in hard money, understaffed, and thoroughly undersupported in terms of nonacademic personnel [26]. The envy which we have engendered is in part personal and in part disciplinary. The peculiar characteristics attributed to surgeons are well known; we must admit that many of them are true. We can change neither the light nor the image in which we are held by our colleagues overnight. However, if we recognize the differing motivation and work habits which characterize the academic surgeon, particularly as related to his colleagues in internal medicine and pediatrics, we can acquire genuine respect for their characteristics, a basis for unity from which they can reflect similar respect, without envy, for our posture. Within the intramural sphere, one must also recognize that the data provided by Zeppa in the SOSSUS summary [38] show both a relative and an absolute erosion of academic manpower in recent years, erosion while the demand for surgical undergraduate education has escalated beyond any dimension heretofore known. Why erosion? One must look beyond compensation as a mechanism for disaffection. The leadership role of the Association’s Committee on Issues under Bernard Gardner has been recognized repeatedly. I call particular attention to their often overlooked study as to why individuals leave academic surgery [7]. To paraphrase briefly and perhaps to understate the major observations, the principal reasons for surgeons leaving academic medicine were lack of a sense of personal patient involvement and poor communication with the chairman of the department. Despite all the denials that are inevitably evoked by the simple mention of this study, I believe this to be true. The special problems of the department chairman have been discussed by both surgeons [26] and internists [3]. Be assured that the chairmen of medicine, as sampled by Braunwald [3], are
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even less sanguine as to the satisfactions of their lofty positions than are their surgical confreres. The high turnover rate and the problems which have become so thoroughly visible in the semi-lay medical press related to legal actions, undertaken particularly by academic surgeons in a whole host of institutions, speak for themselves. If anything, the latter problem is more visible in the postWatergate era than it was at the time of the prior dismal view of the surgical chairman’s role. With respect to compensation, we are somewhat better off than the SOSSUS study [38] might lead one to believe. That study indicated that a full-time assistant professor of surgery made substantially less money than a clinical (volunteer) assistant professor. The observation is correct, but the groups are not entirely comparable. There is a tendency in most universities to promote full-time individuals more rapidly than is the case with volunteer faculty. Indeed, the comparison being made is that of the 35-year-old fulltime assistant professor who earns a fixed sum to the 45year-old clinical assistant professor, who is usually at the absolute peak of his earning powers. There is a real difference in income, but it would be more appropriate to compare individuals by age or by years since completion of residency to achieve less biased comparisons. We do have the means for a more accurate comparison when we consider data regarding income levels displayed by Moore in the SOSSUS summary [38] and compare those with the observations of our own Committee on Issues presented to us just 2 years ago. In general, the compensation of the academic surgeon has improved in recent years in comparison to his colleagues in private practice. It is true that the opportunity for very large earnings which exists for certain selected individuals in private practice generally is not available to academic surgeons. One may argue further that the zeal, enthusiasm, and ability often seen in the bright, young academic surgeon who is so thoroughly well represented in this Association would allow him to earn well
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above the average of his colleagues in private practice. Although I accept this concept, there are others who remind us that affability, availability, and ability, in that order, determine patient referrals. In any case, the discrimination against the academician in terms of compensation, at least with respect to his colleague in private practice in the same community in the same specialty, while still visible appears not so great as it has been in years past. Inevitably one’s compensation must be considered in such discussions and there is certainly nothing that one can add to the fundamental truths etched so clearly 5 years ago by Maloney [21]. The 50-year experiment with post Flexnerian medical school practices which is the source of the salaried fulltime physician should have been amenable to interpretation of outcome. I am persuaded that Maloney enumerated them accurately. He sketched very clearly in that paper and in subsequent editorials [22] the significance of a balanced point of view with clinical involvement and appropriate incentive being the best alternative; it appears to assure the highest productivity measured throughout the sphere of academic life. Clearly, this incentive must be tempered; the cybernetics of the relative costs and payback of patient activities are hard to define [20]. One point that I find unequivocally clear is that it is fundamentally wrong for a physician to return to his university patient fees which exceed the university support provided to that surgeon; to be more specific, it is immoral to have a physician to pay the university for the privilege of working there. Such clarity of insight comes only to him who has been so deceived. Notwithstanding the foregoing, I find much to recommend a sanely planned and honestly administered income plan. The litany of abuses of practice plans and/or income restriction imposed upon surgeons by various and sundry administrative officials is so long as to render me hoarse and bring you to the point of tears. However, a major force in achieving both broad community acceptance of the full-time faculty actively participating in patient care and
1976
maintaining genuine academic goals is an income plan which stimulates some practice and restricts development of large and lucrative practices by the misdirected academic surgeon, What kind of relationship does one build with his practicing colleagues in the same community in the same specialty? It is my strong personal opinion that one must consciously but tactfully deny the demeaning social inquiry, “Do you just teach surgery?’ Furthermore, we must recognize that the bulk of patients will always seek surgeons in private practice. By no means does this imply that the individuals so sought out may be necessarily more capable than those who remain primarily within the walls of the medical school; nevertheless, this is often a component of severe ego stress for the young academic surgeon. Such a situation is inevitable, for an academician must neglect some of his responsibilities of teaching and research if he is u.sfully committed to the market place of patient care as is the surgical practitioner. The best response here again is to face it head-on and to assert that, “Yes, I am a clinical surgeon, and I do see cases on referral .” There is no better answer to the criticism that this statement often evokes than to remind, “How can I possibly teach surgery effectively if I cannot practice it?” We must also realize that our motivation and work habits are quite different from our colleagues who are privately practicing surgery. These differences account for many of the perceived anxieties in that area as well. Consider the “July 1st syndrome” in which the loyal chief resident on June 30 goes into practice and by the evening of the first of July has become the most profound critic of the university and everything for which it stands. What is it that makes the surgical graduate turn so promptly from regard for those who provided his own education? There have been few attempts to describe this often abrasive interface; often they simply defy full description [ 18, 241.The abrasion is most commonly the result of real or imagined advantaged competition for the opposite number, advantaged partly in the sense that the
HIRAM
C. POLK,
JR.: PRESIDENTIAL
academician often has a basic salary for support and may not pay directly the substantial overhead costs so fully felt by the practitioner of surgery and advantaged for the practitioner in the spheres of patient access and income to name only the most visible. When the academician has frequent contact with the practicing surgeon in his community, both may set examples which many well-motivated colleagues will indeed follow. Consider, as an example, a complications conference at a private hospital in Louisville. Although this hospital had long sought and finally achieved a useful affiliation with the University Department of Surgery, there was no semblance of frank discussion of adverse results. To overcome this reticence, it became necessary to present repeatedly in overt detail personal complications. Once started, one or two individual surgeons in leadership positions began to emulate this conduct and within a period of less than 2 years what had been a whitewash session became a superior teaching conference with a genuinely frank discussion of outcome, alternatives, and prevention. No sphere is more consistently neglected than the responsibility of the academic surgeon to all society, seen most clearly in the microcosm of his own family. The divorce rate among academic surgeons seems high and occasionally is the source of rueful embarrassment at reunions. It seems that we experience a higher frequency of difficulty with our children as they attempt to live with the challenges of our increasingly complex life. The absentee parent phenomenon can only go so far, both in terms of what children can sanely tolerate and that for which one’s spouse can be expected to compensate. I am ever more convinced of the value of blocking off time, just as one would for a major case or for an occasional short meeting, to renew oneself by contact with one’s neighbors and by personal activity with one’s family. Not only does one so achieve the immediate goals, but one returns to his primary endeavor mentally and emotionally refreshed. On the national scene, the academic surgeon must take cognizance of the frustrat-
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ingly futile numbers game. It is wryly amusing, when not disheartening, to review the observations made by numerous experts just a very few years ago [35]. They called loudly for additional physicians at any cost, with no realization whatsoever that imperfect geographic and specialty distribution were contingent considerations. On the other hand, there were others who agreed that, while there weren’t enough doctors, there could never be enough doctors and that one must then develop new “systems” of medical care [ll]. It seemed that those espousing such sytems chose this tangent to expound personal prejudices without stating the same. Often that expert was totally unencumbered by any personal experience in actually caring for patients in any setting. Shortly after one starts the numbers game, he must realize that there are more specious comparisons than valid ones being made. Among the worst of these, as pointed out by Fonkalsrud [13] and Schwartz [30] among others, is the inappropriate comparison to other social orders in which patient demand for surgical services varies enormously. Can you imagine the response of some particular individual, perhaps representing a vocal minority, who is told that he must wait 254 years to undergo elective repair of an inguinal hernia? Certain western societies tolerate this well and begin marking the calendar. In this country, the protest buses and ambulances would be embarking for Washington. Other specious examples abound. More often than not, the comparisons being made in the numbers game are deceptively in error, the prejudice of the source persuading the bias. Surely, organized surgery’s response [38] withstands such criticism well without one exception, the a priori assumption that operations done by certified surgeons will in some way be better than those done by noncertified ones is not substantiated and has already been attacked as self-serving in some quarters. Unnecessary surgery and professional standards review considerations are also popular topics. Do not forget that the PSRO movement and the consumer movement, in terms of a “Shoppers Guide to Surgery,” are
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simply rephrasing statements that many of our leading surgical organizations have promulgated for more than 50 years, particularly with reference to frequent consultation, avoidance of overt or occult fee splitting, and establishing valid norms of high quality care. Societal expectations are absolutely appropriate in many of these discussions, and local credentialing appears to be the only mechanism by which we can expect to control deviations. Responsible surgical groups must unite at the local and national level to refine our procedures and to implement these decisions steadfastly. Surely our position is not enhanced by the tendency of some individuals who are neither emotionally nor factually fitted to speak for surgery to level front page blasts at the profession. Rebuttal by the qualified, learned individual always ends up on the back page of the newspaper in fine print. Unfortunately, our good friend who shared his valuable insights with us but a year ago, Harry Schwartz, has been tainted by critics as a hired gun for organized medicine. His observations remain exceedingly worthwhile for each of us to review whether we face a cocktail party quiz on the subjects of unnecessary surgery, excessive fees, and poor results or undertake quiet reflection of the significance of these social and political issues. Schwartz has pointed out that the crisis in health care in the United States is an over-dramatization but there is also doubtlessly room for some overall improvement. He and others have argued that many more of the perceived ills could be corrected by societal changes than will be the case with strictly medical advances. To that end, there are good data from multiple sources that the overall health of a given population is only slightly related to the number of doctors therein. No question exists that we have reached a point at which the anti-intellectual populist movement is dealing harshly with some of our most sacred cows. Governmental regulation is repeatedly proposed as a painless means to a worthy end and we seem so ready
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to acquiesce. The individual who accepts that stance must face with ominous foreboding the observations which were made by de Tocqueville 150 years ago [8]. In Democracy in America, he pointed out that democratic nations have little to fear from visible threats and revolution; however, the kind of despotism which poses the greater danger is that which “would be more extensive and more mild, degrading men without tormenting them”-the government as “sole agent and only arbiter of. . . happiness . . . security . . . necessities . . . pleasures . . . concerns . . . industry . . . and property.” He pointed out that regulation itself is insidious and often even welcomed by the regulated. Ominously, John Cooper [6] has noted that within the fiscal year just ended there was a 30% increase in the regulations printed in the Federal Register, numbering 10,000 pages, or the equivalent of an entire set of the Encyclopaedia Britannica, in a single year! James Kirkpatrick has suggested that we already approach the “tip point” with respect to regulation. There are more than 60,000 federal employees in the regulatory agencies who develop and apply these regulations at a cost of $130 billion per year [ 191. The dangers of regulation are often separately and not collectively perceived, thus representing no overt threat. The regulator himself, the health bureaucrat in our sense, is often an idealist, eager to do good. His function is regulation and the process is ever more and never less. The most palpable problem is undying urge for governmental action: legislate now and repent later, but never deregulate. How can we face this threat of increasing regulation without appearing reactionary? We must face it with a unified, positive, and active program with identifiable results. A generally overlooked plea arose from the floor of this Association at the Denver meeting. One of our more thoughtful members pointed out that the real political and societal influence is achieved only on a local, personal basis, such as is never paralleled or rivaled by the magnitude of national or international recognition or
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JR.: PRESIDENTIAL
representation. We must become the mediator for these difficult problems at tense interfaces: wise solutions now rather than deferred reliance upon the innate vision and fairness of the dispassionate but often uninformed regulator. Manpower and distribution are now the immediate goals of the regulators. Yet, within but 3 years there has already been a decided shift in medical school graduates toward primary care disciplines, particularly family practice. The Residency Review Committees, especially within surgery, are already exercising careful judgment in the exclusion of poor and marginal residencies as promptly as present guidelines allow. Surgery and medicine as a whole are now responding in an immediate and effective way, in less than 5 years from the clarification of the problem. If there is to be further regulation in surgery, how much better a professional consideration of operative mortality rate adjusted for severity of illness and frequency of coexisting illness [5] as an expression of surgical quality! Contrast that with an FDA for surgeons, as has been promulgated by those whose tongues are quicker than their minds [3 11. It is a reflection of the times as well as the relative stance of the individual to review the comments of the new Secretary of Commerce, Elliott Richardson, when within the administration and when disaffected and without it. As a representative of the Nixon administration he felt that medicine could do much more; [28] because government paid so much of the overall health costs, it certainly had a voice in regulation. However, he even then pointed out that one must look beyond easy solutions to second-generation effects induced by proposed changes. Perhaps bespeaking his own family’s surgical background, he encouraged description and definition of quality medical care to the extent feasible. Three years later, Richardson suggested that we definitely limit government involvement in medicine, seeking more responsible private behavior on the part of physicians [29]. He counseled that we accept
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some procedural inefficiency in order to achieve longterm consumer input. Some chords were similar. Again, he counseled a more thoroughly considered approach to systematic change. Richardson also stressed the importance of preserving humanist values as we move to a method of medical care which might approach an assembly line psychology. Professional competence and humanism, how? There is no better example than Judah Folkman’s provocative address to a graduating class entitled “Don’t Practice on Me.” He reminded the graduates that a good physician always practices [12]. His comments brought to mind the response of the daughter of an orthopedic surgeon to my query as to where her father practiced who said, “He doesn’t practice anymore; he’s a real doctor now.” She missed the broad significance of the term; let us be certain we do not! Folkman reminded us that patients want to receive the best possible care we can provide. But do we not always practice? Was there ever an operation that could not be improved upon? As we deal sequentially in our professional and personal development, we push back what amounts to personal ignorance only to find ourselves in the position similar to that of most of the members of this Association today, pushing back the limit of disciplinary ignorance of medicine or surgery as a whole. It is absolutely essential that we continue to ask “Why?” with an honest and self effacing appreciation of the inevitable uncertainties of medical practice. We must particularly appreciate these uncertainties, all the more so with the tendency in recent years for many of our associates to flirt disgracefully with the Delilah of the press. All of the conscientious concern against misleading lay publicity has been negated by a few self-serving individuals in recent years. The individual who perhaps has less education than some of us finds it difficult to understand how one can accomplish a human heart transplant and at the same time not be able to cure bacterial pneumonia. Surely we have public accountability. Let us always couch
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those reports in the scientist’s quest for truth rather than in the insecure man’s grasp for notoriety. NOW for those foci of disciplinary ignorance! In some instances SOSSUS speaks both persuasively and validly as to the real social and scientific value of research. Today, the climate for continuity of that thread of genuine inquiry could scarcely be less favorable. Speak your concerns directly to the President’s Biomedical Research Panel, sharply aware of the reservations of Lewis Thomas and others; i.e., the development and maintenance of research skills must appreciate that contractual research is limited in capacity and that basic and general support in a good atmosphere is the source of genuine advances [33]. Few bodies within surgery have the capacity of this Association to exemplify unity: with our colleagues, with the consumers who have been represented on our panels, with the insurance industry and with the legal profession whose members have appeared on our programs, with administrative officials both in the university and throughout the medical center, and, most especially, unity within surgery as a discipline. We have developed a program within the Association which generally has produced in equal parts scientific endeavor and discussions that fall in the spheres of social, educational, political, and economic considerations. We must remember that more than 50% of the membership of the American College of Surgeons is not comprised of persons in surgical specialties. The Association must continue its effort in bringing individuals from all the spheres of academic life into our program and into the mainstream of the Association’s activities. We must continue to provide an environment which speaks to the lasting truths of academic inquiry and yet allows such inquiry to be continuously conducted. We must continue to be honest and conscientious at both the national and local level in presenting our own results, a point so sadly underlined by the total failure of the critical incident study within the SOSSUS
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endeavor. Inevitably, the good and evil of man will determine what our tip point is at this particular time. I close with some simple comments. In response to the multitudinous demands upon the academic surgeon, we all realize “too busy” is an answer synonomous with “I don’t care enough.” You, the university surgeon in the fullest sense, must never forget that our greatest organizational strengths mirror those personal qualities which have always identified the good doctor, skill, wisdom, and conscience. REFERENCES I. Anlyan, W. G. What the current medical student desires from the surgical faculty. Bull. Amer. Coil. Surg. Jul.-Aug.:7, 197 1. 2. Ballinger, W. F., and Collins, J. A. Integration of full-time and voluntary surgeons in a university hospital. Surgery 74:488, 1973. 3. Braunwald, E. Remarks made to Spring Meeting of Council of Academic Societies, Bethesda, Md., March 3, 1975. 4. Bricker, E. The private surgeon in a university hospital. Surgery 74~494, 1973. 5. Campbell, D. A. The measure of a surgeon. Arch. Surg. 110:464, 1975. 6. Cooper, J. A. D. President’s Report to the Association of American Medical Colleges, Washington, D.C., November, 1975. 7. Curreri, P. W., Zimmermann, C. E., Jaffe, B. M., Mackenzie, J. R., Nance, F. C., Zollinger, R., Jr., and Gardner, B. Survey of employment satisfaction in academic surgery./. Surg. Res. 17,215, 1974. 8. de Tocqueville, A. Democracy in America. New American Library of World Literature, New York, 1956. 9. Dunphy, J. E. Not from a curriculum. Amer. J. Surg. 116,408, 1968. 10. Eckert, C. Specialization and superspecialization in surgery. Arch. Surg. 109, 139, 1974. 11. Fein, R. Can the ‘doctor shortage’ be solved? Hosp. Pratt. Apr.:73, 1971. 12. Folkman, J. M. Don’t practice on me. Harvard Med. Alumni Bull. 49~39, 1975. 13. Fonkalsrud, E. W. Reassessment of surgical specialty training in the United States. Arch. Surg. 104:759, 1972. 14. Fonkalsrud, E. W. Too many medical society.meetings? Arch. Surg. 110:463, 1975. 15. Freiman, D. G. The curriculum revolution: Second thoughts. N. Engl. J. Med. 288:1240, 1973. 16. Goldhaber, S. 2. Medical education: Harvard reverts to tradition. Science 181:1027, 1973. 17. Hanlon, C. R. Discussion of DeWeese, J. A., Blais-
HIRAM C. POLK, JR.: PRESIDENTIAL dell, F. W., Foster, J. H., Optimal resources for vascular surgery. Arch. Surg. 105:948, 1972. 18. Johnston, J. H., Jr. The private surgeon looks at academia. Surgery 74:505,1973. 19. Kirkpatrick, J. J. The new national nightmare. Nation’s Business Aug.:ll, 1975. 20. Leape, L. L., Busby, D. D., Leming, J. C., Olson, M. I., and Humphrey, L. J. Who pays for medical education?Surgery 72:16, 1972. 21. Maloney, J. V., Jr. A report on the role of economic motivation in the performance of medical school faculty. Surgery 68:1, 1970. 22. Maloney, J. V., Jr. Doctors, dollars, and social unrest. Surg. Gynecol. Obstet. 132:492, 1971. 23. Medawar, P. B. Some follies of prediction. Hosp. Pratt. Apr.:73, 1975. 24. Moore, F. D. University in American surgery. Surgery 44:1, 1958. 25. Moore, F. D. Surgical teaching in the development of clinical competence. J. Amer. Med. Ass. 202:122, 1967. 26. Orloff, M. J. The university department of surgery: Its structure and role in American medicine. Surgery 72:1, 1972. 27. Parsons, T., and Platt, G. M. The American University. Harvard University Press, Cambridge,
Mass., 1973. 28. Richardson, E. L. We cannot strive for anything less. Bull. Amer. Coil. Surg. Jan.:17, 1971.
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29. Richardson, E. L. Shattuck Lecture-“The old order changeth, yielding place to new.” Perspectives on the health “revolution.” N. Engl. J. Med. 291:283,1974. 30. Schwartz, H. The Case for American Medicine. A Realistic Look aI Our Health Care System. David
McKay, New York, 1972. 31. Spodick, D. H. Numerators without denominators: There is no FDA for the surgeon. J. Amer. Med. Ass. 232:35, 1975.
32. Thomas, L. The Lives of a Cell. Viking Press, New York, 1974. 33. Varco, R. Recertification and subcertification. Paper presented at the Clinical Congress at the A.C.S., San Francisco, Calif., Oct. 15, 1975. 34. Wangensteen, 0. Historical aspects of some surgical training programs: A plea to retain the surgical generalist in the academic arena. Surgery 72:692, 1972. 35. Williams, G. Quality versus quantity in American
medical education. Science 153~956,1966. 36. Woodhall, B. The place of the medical school in the university. S. Med. J. 64:259, 1971. 37. Zeppa, R. Remarks to the American Surgical Association. Colorado Springs, Colo., May 2, 1974. 38. Zuidema, G. D. (Director). Surgery in the United States. A Summary Reporr of ihe Study on Surgical Services for the United Slates. The American
College of Surgeons and The American Surgical Association, 1975.
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RESEARCH
PRESIDENTIAL United
ADDRESS
We Stand, HIRAM
Divided
We . . . .’
C. POLK, JR., M.D.
Department of Surgery, University of Louisville School of Medicine, Health Sciences Center, Louisville, Kentucky 40201 Submitted for publication December I. 1975
I come before you today with the deepest appreciation to discharge the penultimate responsibility of the Presidency of our Association. On such an occasion, three statements are commonly made. The first relates to the honor for the opportunity; the second may well be a conscientious review of the spoken words of all prior presidents; the third implies an unending concern as to the nature and subject of this address. I begin by denying all of these tenets. The honor involved is better expressed as gratification for working at a variety of responsibilities as this Association grew into a significant influence in American surgery and as an expanding one in the broader senseof academic and medical life. I specifically avoid the review of remarks of my predecessors at times such as these for fear that all the incisive ideas would be disclosed to have been theirs and the less judicious ones mine. The choice of a subject for this occasion concerned me only slightly, for I was certain that some circumstance would disclose a common thread for matters of concern to the Association and bring an appropriate response to mind. The tragic accuracy of that premonition was reflected in the evening hours of June 24 when I learned of the death of our colleague and my close friend, Ted Drapanas. In the many days of genuine good times and serious concern we spent together, there was no principle which was more consistently considered for our deliberations ‘The Presidential Address presented to the Ninth Annual Meeting of the Association for Academic Surgery, Minneapolis, Minnesota, November 13-15, 1975.
than that which I share with you today. That principle is a relatively simple and solitary approach to many of our present problems and one with which this Association may be particularly well equipped to deal. Recall, however, Mencken’s statement that for every major problem there is a solution which is simple, direct, and wrong! Further, recall that I come here to review my prejudicial thoughts with you and to convince you that they are valid. I am further ever mindful of the remarks of Medawar [23] who demonstrated the folly of prediction by the remarks of the distinguished surgeon, Lord Moynihan. Undaunted, my proposal is simply that a conscious sense of unity in our affairs and at all our personal and professional interfaces can minimize, palliate, or even cure many of the ills that confront today’s surgical academician. What are the problems that face us? With no primacy of order, one must consider research funding, human experimentation, true disclosure, the antiintellectual populist movement, recertification, professional liability, the number and influence of the size and composition of our undergraduate and postgraduate training programs, the role of minorities with a special concern for our associates, now discriminatingly designated as “FMG’s,” national health insurance, peer review, governmental regulation, and the morality of personal compensation, just to mention a few! What is this unity? Is this the unity of this homogeneousgroup meeting here today? No, I am speaking of unity in the broadest sense:
127 Copyright D 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
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with all our society, with all our colleagues in academic life, with all our colleagues in the biomedical sciences, and most especially among all of us who are privileged to toil as surgeons. Assuming that I can persuade you as to the value of unity, one attitudinal postulate is essential: Before we can take that first step toward it, conscious effort to depersonalize issues is a sine qua non! Not so very long ago, Richard Varco shared with me valuable insight into this requisite when he asked, “Do you notice how often some people try to make their own personal problems great national issues?” If we can rise above this particular hang-up, unity becomes attainable. Why unity? Frequently, the process of common reasoning produces solutions of a broader and firmer nature. Unity allows a concerted response from individuals whose counsel has allowed answers, inevitably providing greater influence: in two words, more clout. To begin to consider the benefits of such unity, one must consider the myriad interfaces of the academic surgeon. SPHERES OF CONTACT In the broadest human sense, the academic surgeon must concern himself with all of society; the ideal unit representing just that is his family and secondary nonprofessional contacts and friends. The family tragedies of many of our colleagues are sufficient to underline how frequently we assign secondary or even tertiary importance to this aspect of our lives. Yet it can be the balance wheel which places many of the other stresses and possible solutions in more appropriate perspective. Of course, the academic surgeon is ever concerned with his patients and with related citizens, now unfortunately depersonalized as consumers. He must also relate to his government and most especially to that arm involved in the health process and the planning thereof and must develop the various interfaces with other health professionals, with hospitals, and most especially with other academicians.
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Now, what are the purely academic interfaces of the Association’s members? Herein, he or she must relate again to his patients and to students and residents. We must relate to a variety of administrative officials, including the chairman of the department, the dean, the vice-president or provost, as the case may be, and, inescapably, hospital administrators. A further relationship essential to our identity is that with our nonsurgical biomedical colleagues. Indeed, Anlyan has succinctly reviewed the contrasting demands involved for the surgical educator and investigator [l]. It is in this particular arena, the intramural one, if you will, that many of the more overt concerns of the members of this Association may be manifested. However, this second sphere of influence inevitably turns to a third: all of medicine as the larger community. This is most clearly reflected in the relationships that one must secure with colleagues in similar disciplines within the locality. This effective liaison must also extend to all the practitioners of medicine and related health professionals with whom one works. Be reminded that the academic surgeon is viewed as a hero when he is more than 100 miles away from home and as the devil himself in his own locale! Beyond all of this is the national dimension of one’s surgical activities, often the pervasive ambition of the younger academic surgeon and the disappointing bane of the senior man who has tasted (or, more appropriately, swallowed) the fruit and found it bitter. Dunphy’s analogy of the jet set professor is both valid and damning [9]. To choose between responsibilities continues to try even the Solomons among us. Indeed, the proliferation of societies and associations speak to a conflicting series of needs [14]. One group is exclusive, the other inclusive. One club tends to attract more senior members while another draws junior participants. One society becomes large, the other seeks to remain small. As one priority is set, the balancing or opposing characteristic appears, almost by sleight of hand.
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C. POLK,
JR.: PRESIDENTIAL
EXEMPLIAE GRATIAE Neither time nor common sense allows a point by point discussion of how unity with one’s fellow man, whatever the dimension, is an appropriate response to our concerns. However, it is germane to discuss enough examples to persuade you of the validity of the concept and to stimulate you to develop applications and significance far beyond what I see from my limited vantage point. Let us first consider the intramural interfaces of the academic surgeon. Undergraduate education is where it all begins and ends! Our dean is prone to remind us that we, first and foremost, operate a schoolhouse. The undergraduate medical curriculum appears to be in a process of continual cyclical variation [16], in part because of the inevitable gap between expectation and actual experience [ 151. Indeed, curricular revision does not seem to be able to close this gap. The cycle seemsobligate; only the length and interval seem to vary. However, the dismembered surgical disciplines and the erstwhile department are notoriously ineffective in competing for curricular time. With each passing cycle of curricular revision, the surgical proportion thus becomes increasingly miniscule. This allows even more students, who choose disciplines other than surgical careers, to go forward into their life’s work with an inappropriate understanding of one of the only four therapeutic modalities known to man. Furthermore, it sharply impairs the ability of the department and its divisions to compete for quality students by virtue of exposure alone. Further, consider the relative impact of a unified, intact department of surgery upon discussions with deans and other university and hospital administrative officers. There is no clearer example of the divide-and-conquer concept than the ease with which dismembered departments are managed by administrators at all levels. Without choosing one discipline as an example, consider how much can really go wrong in a three-man division of a 400-member faculty medical school that will get the dean’s consistent at-
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tention. Compare this with the impact that a 3%man department’s support of the position of the three-man division can bring to bear, not only in the dean’s office, but in all the councils of the school of medicine. Not to be overlooked is the benefit of a unified approach to mutual financial, technical, and facility needsinvolved in such a department. Unity’s opposite number is fragmentation. But first, what is there to share between the surgical disciplines? Does the cardiac surgeon have more in common with the modern cardiologist or his present colleague in (general) surgery. Surely he has much in common with both. The individual with insight perceives that he can retain the best of his common ground with the parent surgical discipline and build new and lasting dimensions of common thought and concern with the medical cardiologists. The physicians oriented toward medical and surgical cardiology have requisite awareness of abnormalities of cardiac rhythm and ventricular function curves. Surely these mean most in addition to those which the cardiac surgeon shares with his other surgical colleagues: hemostasis, infection, foreign body failure, and overall supportive care. Beyond common interests, there are the surgical bridgetenders [24], those individuals who develop skills enabling them to evaluate developments in related disciplines and bring them to bear upon the whole spectrum of surgery. Realize how precisely the evaluation of surgical intensive care skills relates to the impact of complicated and precise postoperative study of the cardiac surgical patient. On an even broader plane, the pervading influence of infection and its limitations upon further advances in all the surgical disciplines exemplifies a common ground, requiring judicious input from the so-called basic sciences. In considering further fragmentation in surgery, one may question, as has Orloff [26], that the nominal courtesy of denoting subspecialties as superspecialties went very well until some of those so addressed began to believe all of the connotations therein.
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Further, continued specialization has been associated with identifiable second-generation deterioration of insight and imagination in the discipline. The most pathetic example can be found in the letter quoted, arguing or, rather, demanding, that a division be made a department. Many surgical scholars have long appreciated that general surgery is purely a general education in surgery [25]. Wangensteen, among others, argues convincingly that breadth of understanding is essential to discovery [34], and Eckert further pointed out that advances in most specialties often have been made by the broadly trained surgeon [lo]. Both Varco [33] and Hanlon [17] have asked whether the further specialization of surgery represents professionalism in the highest sense or a misdirected sense of elitism. Does it indeed serve selfish interests or is it for the common good? Where is the tip point, that moment at which conditions change not in degree, but in direction? When does “good” become “bad”? If further specialization continues in an uncoordinated way, excessive fragmentation will surely morsellate all of surgery. The medicolegal complications of further specialization must also be acknowledged. Are our senior, respected, and innovative leaders guilty of overdramatization when they describe such fragmentation as “monsters born while reason sleeps”? Is further specialization in the common interest? Will it not further increase unavailability, increase maldistribution, and surely increase costs? On the other hand, the likelihood of discontinuing a previously identified specialty is surely not great; indeed, it has been likened to the difficulty in relocating the community cemetery. Can we not accept the thesis that the whole of surgery has more in common than it has in discord? The conscientious definition of further specialty development will be a continuing need of our discipline. Turning from consideration of extramural as well as intramural surgical fragmentation, the academic surgeon must look to his relationship with his colleagues within the
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university [36]. Talcott Parsons has pointed out [27] that the professional schools come closest to integration of the university’s social and intellectual responsibilities. Further still, training as specialists in the applied professions is an ultimate application of knowledge for solving problems of high social value but, at the same time, implementing the cognitive resources of the university. Our university citizenship separates us from tradesmanship; we must appreciate that citizenship and the unity with the scholarly community that it implies. We recognize the valuable but innately divisive concept of the change of clothes for the operating room. Moore has pointed out that this alone tends to isolate us, not only from microbial threats but from a frequent and vital interface with our nonsurgical colleagues [25]. Indeed, many respected individuals in medical disciplines have literally not seen an operation in decades, an occurrence within the vividly recent memory of each of us. Surely they should not spend every morning watching the technical feats of operative legerdemain. Nevertheless, are not these physicians obligated to the patient they see tomorrow to be currently aware of both the opportunities and the limitations of modern surgery? Recall a further effect of this same barrier. Our operating room sanctuary competes all too effectively with bedside teaching, a criticism widely leveled at surgery only 10 years ago. Only a major national and sustained local effort succeeded in retaining, in the face of a persistent barrage from other disciplines, our primary role in undergraduate education. Although we must be aware of the difficulties that the nonmedical constituents of the university have in perceiving our problems. our seemingly spendthrift ways, and OUI mirage of wealth, even greater concern must be directed toward the misunderstanding oj surgery and surgeons by other clinical de. partments and their members. Despite the common assumption that departments oj surgery are fiscally well off, are overstaffed and travel excessively while leaving all the
HIRAM
C. POLK,
JR.: PRESIDENTIAL
work to the residents, Orloff found that, by comparison with other clinical departments, surgical departments are traditionally underfinanced, particularly in hard money, understaffed, and thoroughly undersupported in terms of nonacademic personnel [26]. The envy which we have engendered is in part personal and in part disciplinary. The peculiar characteristics attributed to surgeons are well known; we must admit that many of them are true. We can change neither the light nor the image in which we are held by our colleagues overnight. However, if we recognize the differing motivation and work habits which characterize the academic surgeon, particularly as related to his colleagues in internal medicine and pediatrics, we can acquire genuine respect for their characteristics, a basis for unity from which they can reflect similar respect, without envy, for our posture. Within the intramural sphere, one must also recognize that the data provided by Zeppa in the SOSSUS summary [38] show both a relative and an absolute erosion of academic manpower in recent years, erosion while the demand for surgical undergraduate education has escalated beyond any dimension heretofore known. Why erosion? One must look beyond compensation as a mechanism for disaffection. The leadership role of the Association’s Committee on Issues under Bernard Gardner has been recognized repeatedly. I call particular attention to their often overlooked study as to why individuals leave academic surgery [7]. To paraphrase briefly and perhaps to understate the major observations, the principal reasons for surgeons leaving academic medicine were lack of a sense of personal patient involvement and poor communication with the chairman of the department. Despite all the denials that are inevitably evoked by the simple mention of this study, I believe this to be true. The special problems of the department chairman have been discussed by both surgeons [26] and internists [3]. Be assured that the chairmen of medicine, as sampled by Braunwald [3], are
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even less sanguine as to the satisfactions of their lofty positions than are their surgical confreres. The high turnover rate and the problems which have become so thoroughly visible in the semi-lay medical press related to legal actions, undertaken particularly by academic surgeons in a whole host of institutions, speak for themselves. If anything, the latter problem is more visible in the postWatergate era than it was at the time of the prior dismal view of the surgical chairman’s role. With respect to compensation, we are somewhat better off than the SOSSUS study [38] might lead one to believe. That study indicated that a full-time assistant professor of surgery made substantially less money than a clinical (volunteer) assistant professor. The observation is correct, but the groups are not entirely comparable. There is a tendency in most universities to promote full-time individuals more rapidly than is the case with volunteer faculty. Indeed, the comparison being made is that of the 35-year-old fulltime assistant professor who earns a fixed sum to the 45year-old clinical assistant professor, who is usually at the absolute peak of his earning powers. There is a real difference in income, but it would be more appropriate to compare individuals by age or by years since completion of residency to achieve less biased comparisons. We do have the means for a more accurate comparison when we consider data regarding income levels displayed by Moore in the SOSSUS summary [38] and compare those with the observations of our own Committee on Issues presented to us just 2 years ago. In general, the compensation of the academic surgeon has improved in recent years in comparison to his colleagues in private practice. It is true that the opportunity for very large earnings which exists for certain selected individuals in private practice generally is not available to academic surgeons. One may argue further that the zeal, enthusiasm, and ability often seen in the bright, young academic surgeon who is so thoroughly well represented in this Association would allow him to earn well
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above the average of his colleagues in private practice. Although I accept this concept, there are others who remind us that affability, availability, and ability, in that order, determine patient referrals. In any case, the discrimination against the academician in terms of compensation, at least with respect to his colleague in private practice in the same community in the same specialty, while still visible appears not so great as it has been in years past. Inevitably one’s compensation must be considered in such discussions and there is certainly nothing that one can add to the fundamental truths etched so clearly 5 years ago by Maloney [21]. The 50-year experiment with post Flexnerian medical school practices which is the source of the salaried fulltime physician should have been amenable to interpretation of outcome. I am persuaded that Maloney enumerated them accurately. He sketched very clearly in that paper and in subsequent editorials [22] the significance of a balanced point of view with clinical involvement and appropriate incentive being the best alternative; it appears to assure the highest productivity measured throughout the sphere of academic life. Clearly, this incentive must be tempered; the cybernetics of the relative costs and payback of patient activities are hard to define [20]. One point that I find unequivocally clear is that it is fundamentally wrong for a physician to return to his university patient fees which exceed the university support provided to that surgeon; to be more specific, it is immoral to have a physician to pay the university for the privilege of working there. Such clarity of insight comes only to him who has been so deceived. Notwithstanding the foregoing, I find much to recommend a sanely planned and honestly administered income plan. The litany of abuses of practice plans and/or income restriction imposed upon surgeons by various and sundry administrative officials is so long as to render me hoarse and bring you to the point of tears. However, a major force in achieving both broad community acceptance of the full-time faculty actively participating in patient care and
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maintaining genuine academic goals is an income plan which stimulates some practice and restricts development of large and lucrative practices by the misdirected academic surgeon, What kind of relationship does one build with his practicing colleagues in the same community in the same specialty? It is my strong personal opinion that one must consciously but tactfully deny the demeaning social inquiry, “Do you just teach surgery?’ Furthermore, we must recognize that the bulk of patients will always seek surgeons in private practice. By no means does this imply that the individuals so sought out may be necessarily more capable than those who remain primarily within the walls of the medical school; nevertheless, this is often a component of severe ego stress for the young academic surgeon. Such a situation is inevitable, for an academician must neglect some of his responsibilities of teaching and research if he is u.sfully committed to the market place of patient care as is the surgical practitioner. The best response here again is to face it head-on and to assert that, “Yes, I am a clinical surgeon, and I do see cases on referral .” There is no better answer to the criticism that this statement often evokes than to remind, “How can I possibly teach surgery effectively if I cannot practice it?” We must also realize that our motivation and work habits are quite different from our colleagues who are privately practicing surgery. These differences account for many of the perceived anxieties in that area as well. Consider the “July 1st syndrome” in which the loyal chief resident on June 30 goes into practice and by the evening of the first of July has become the most profound critic of the university and everything for which it stands. What is it that makes the surgical graduate turn so promptly from regard for those who provided his own education? There have been few attempts to describe this often abrasive interface; often they simply defy full description [ 18, 241.The abrasion is most commonly the result of real or imagined advantaged competition for the opposite number, advantaged partly in the sense that the
HIRAM
C. POLK,
JR.: PRESIDENTIAL
academician often has a basic salary for support and may not pay directly the substantial overhead costs so fully felt by the practitioner of surgery and advantaged for the practitioner in the spheres of patient access and income to name only the most visible. When the academician has frequent contact with the practicing surgeon in his community, both may set examples which many well-motivated colleagues will indeed follow. Consider, as an example, a complications conference at a private hospital in Louisville. Although this hospital had long sought and finally achieved a useful affiliation with the University Department of Surgery, there was no semblance of frank discussion of adverse results. To overcome this reticence, it became necessary to present repeatedly in overt detail personal complications. Once started, one or two individual surgeons in leadership positions began to emulate this conduct and within a period of less than 2 years what had been a whitewash session became a superior teaching conference with a genuinely frank discussion of outcome, alternatives, and prevention. No sphere is more consistently neglected than the responsibility of the academic surgeon to all society, seen most clearly in the microcosm of his own family. The divorce rate among academic surgeons seems high and occasionally is the source of rueful embarrassment at reunions. It seems that we experience a higher frequency of difficulty with our children as they attempt to live with the challenges of our increasingly complex life. The absentee parent phenomenon can only go so far, both in terms of what children can sanely tolerate and that for which one’s spouse can be expected to compensate. I am ever more convinced of the value of blocking off time, just as one would for a major case or for an occasional short meeting, to renew oneself by contact with one’s neighbors and by personal activity with one’s family. Not only does one so achieve the immediate goals, but one returns to his primary endeavor mentally and emotionally refreshed. On the national scene, the academic surgeon must take cognizance of the frustrat-
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ingly futile numbers game. It is wryly amusing, when not disheartening, to review the observations made by numerous experts just a very few years ago [35]. They called loudly for additional physicians at any cost, with no realization whatsoever that imperfect geographic and specialty distribution were contingent considerations. On the other hand, there were others who agreed that, while there weren’t enough doctors, there could never be enough doctors and that one must then develop new “systems” of medical care [ll]. It seemed that those espousing such sytems chose this tangent to expound personal prejudices without stating the same. Often that expert was totally unencumbered by any personal experience in actually caring for patients in any setting. Shortly after one starts the numbers game, he must realize that there are more specious comparisons than valid ones being made. Among the worst of these, as pointed out by Fonkalsrud [13] and Schwartz [30] among others, is the inappropriate comparison to other social orders in which patient demand for surgical services varies enormously. Can you imagine the response of some particular individual, perhaps representing a vocal minority, who is told that he must wait 254 years to undergo elective repair of an inguinal hernia? Certain western societies tolerate this well and begin marking the calendar. In this country, the protest buses and ambulances would be embarking for Washington. Other specious examples abound. More often than not, the comparisons being made in the numbers game are deceptively in error, the prejudice of the source persuading the bias. Surely, organized surgery’s response [38] withstands such criticism well without one exception, the a priori assumption that operations done by certified surgeons will in some way be better than those done by noncertified ones is not substantiated and has already been attacked as self-serving in some quarters. Unnecessary surgery and professional standards review considerations are also popular topics. Do not forget that the PSRO movement and the consumer movement, in terms of a “Shoppers Guide to Surgery,” are
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simply rephrasing statements that many of our leading surgical organizations have promulgated for more than 50 years, particularly with reference to frequent consultation, avoidance of overt or occult fee splitting, and establishing valid norms of high quality care. Societal expectations are absolutely appropriate in many of these discussions, and local credentialing appears to be the only mechanism by which we can expect to control deviations. Responsible surgical groups must unite at the local and national level to refine our procedures and to implement these decisions steadfastly. Surely our position is not enhanced by the tendency of some individuals who are neither emotionally nor factually fitted to speak for surgery to level front page blasts at the profession. Rebuttal by the qualified, learned individual always ends up on the back page of the newspaper in fine print. Unfortunately, our good friend who shared his valuable insights with us but a year ago, Harry Schwartz, has been tainted by critics as a hired gun for organized medicine. His observations remain exceedingly worthwhile for each of us to review whether we face a cocktail party quiz on the subjects of unnecessary surgery, excessive fees, and poor results or undertake quiet reflection of the significance of these social and political issues. Schwartz has pointed out that the crisis in health care in the United States is an over-dramatization but there is also doubtlessly room for some overall improvement. He and others have argued that many more of the perceived ills could be corrected by societal changes than will be the case with strictly medical advances. To that end, there are good data from multiple sources that the overall health of a given population is only slightly related to the number of doctors therein. No question exists that we have reached a point at which the anti-intellectual populist movement is dealing harshly with some of our most sacred cows. Governmental regulation is repeatedly proposed as a painless means to a worthy end and we seem so ready
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to acquiesce. The individual who accepts that stance must face with ominous foreboding the observations which were made by de Tocqueville 150 years ago [8]. In Democracy in America, he pointed out that democratic nations have little to fear from visible threats and revolution; however, the kind of despotism which poses the greater danger is that which “would be more extensive and more mild, degrading men without tormenting them”-the government as “sole agent and only arbiter of. . . happiness . . . security . . . necessities . . . pleasures . . . concerns . . . industry . . . and property.” He pointed out that regulation itself is insidious and often even welcomed by the regulated. Ominously, John Cooper [6] has noted that within the fiscal year just ended there was a 30% increase in the regulations printed in the Federal Register, numbering 10,000 pages, or the equivalent of an entire set of the Encyclopaedia Britannica, in a single year! James Kirkpatrick has suggested that we already approach the “tip point” with respect to regulation. There are more than 60,000 federal employees in the regulatory agencies who develop and apply these regulations at a cost of $130 billion per year [ 191. The dangers of regulation are often separately and not collectively perceived, thus representing no overt threat. The regulator himself, the health bureaucrat in our sense, is often an idealist, eager to do good. His function is regulation and the process is ever more and never less. The most palpable problem is undying urge for governmental action: legislate now and repent later, but never deregulate. How can we face this threat of increasing regulation without appearing reactionary? We must face it with a unified, positive, and active program with identifiable results. A generally overlooked plea arose from the floor of this Association at the Denver meeting. One of our more thoughtful members pointed out that the real political and societal influence is achieved only on a local, personal basis, such as is never paralleled or rivaled by the magnitude of national or international recognition or
HIRAM
C. POLK,
JR.: PRESIDENTIAL
representation. We must become the mediator for these difficult problems at tense interfaces: wise solutions now rather than deferred reliance upon the innate vision and fairness of the dispassionate but often uninformed regulator. Manpower and distribution are now the immediate goals of the regulators. Yet, within but 3 years there has already been a decided shift in medical school graduates toward primary care disciplines, particularly family practice. The Residency Review Committees, especially within surgery, are already exercising careful judgment in the exclusion of poor and marginal residencies as promptly as present guidelines allow. Surgery and medicine as a whole are now responding in an immediate and effective way, in less than 5 years from the clarification of the problem. If there is to be further regulation in surgery, how much better a professional consideration of operative mortality rate adjusted for severity of illness and frequency of coexisting illness [5] as an expression of surgical quality! Contrast that with an FDA for surgeons, as has been promulgated by those whose tongues are quicker than their minds [3 11. It is a reflection of the times as well as the relative stance of the individual to review the comments of the new Secretary of Commerce, Elliott Richardson, when within the administration and when disaffected and without it. As a representative of the Nixon administration he felt that medicine could do much more; [28] because government paid so much of the overall health costs, it certainly had a voice in regulation. However, he even then pointed out that one must look beyond easy solutions to second-generation effects induced by proposed changes. Perhaps bespeaking his own family’s surgical background, he encouraged description and definition of quality medical care to the extent feasible. Three years later, Richardson suggested that we definitely limit government involvement in medicine, seeking more responsible private behavior on the part of physicians [29]. He counseled that we accept
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some procedural inefficiency in order to achieve longterm consumer input. Some chords were similar. Again, he counseled a more thoroughly considered approach to systematic change. Richardson also stressed the importance of preserving humanist values as we move to a method of medical care which might approach an assembly line psychology. Professional competence and humanism, how? There is no better example than Judah Folkman’s provocative address to a graduating class entitled “Don’t Practice on Me.” He reminded the graduates that a good physician always practices [12]. His comments brought to mind the response of the daughter of an orthopedic surgeon to my query as to where her father practiced who said, “He doesn’t practice anymore; he’s a real doctor now.” She missed the broad significance of the term; let us be certain we do not! Folkman reminded us that patients want to receive the best possible care we can provide. But do we not always practice? Was there ever an operation that could not be improved upon? As we deal sequentially in our professional and personal development, we push back what amounts to personal ignorance only to find ourselves in the position similar to that of most of the members of this Association today, pushing back the limit of disciplinary ignorance of medicine or surgery as a whole. It is absolutely essential that we continue to ask “Why?” with an honest and self effacing appreciation of the inevitable uncertainties of medical practice. We must particularly appreciate these uncertainties, all the more so with the tendency in recent years for many of our associates to flirt disgracefully with the Delilah of the press. All of the conscientious concern against misleading lay publicity has been negated by a few self-serving individuals in recent years. The individual who perhaps has less education than some of us finds it difficult to understand how one can accomplish a human heart transplant and at the same time not be able to cure bacterial pneumonia. Surely we have public accountability. Let us always couch
136
JOURNAL
OF SURGICAL
RESEARCH:
those reports in the scientist’s quest for truth rather than in the insecure man’s grasp for notoriety. NOW for those foci of disciplinary ignorance! In some instances SOSSUS speaks both persuasively and validly as to the real social and scientific value of research. Today, the climate for continuity of that thread of genuine inquiry could scarcely be less favorable. Speak your concerns directly to the President’s Biomedical Research Panel, sharply aware of the reservations of Lewis Thomas and others; i.e., the development and maintenance of research skills must appreciate that contractual research is limited in capacity and that basic and general support in a good atmosphere is the source of genuine advances [33]. Few bodies within surgery have the capacity of this Association to exemplify unity: with our colleagues, with the consumers who have been represented on our panels, with the insurance industry and with the legal profession whose members have appeared on our programs, with administrative officials both in the university and throughout the medical center, and, most especially, unity within surgery as a discipline. We have developed a program within the Association which generally has produced in equal parts scientific endeavor and discussions that fall in the spheres of social, educational, political, and economic considerations. We must remember that more than 50% of the membership of the American College of Surgeons is not comprised of persons in surgical specialties. The Association must continue its effort in bringing individuals from all the spheres of academic life into our program and into the mainstream of the Association’s activities. We must continue to provide an environment which speaks to the lasting truths of academic inquiry and yet allows such inquiry to be continuously conducted. We must continue to be honest and conscientious at both the national and local level in presenting our own results, a point so sadly underlined by the total failure of the critical incident study within the SOSSUS
VOL. 20, NO. 3, MARCH
1976
endeavor. Inevitably, the good and evil of man will determine what our tip point is at this particular time. I close with some simple comments. In response to the multitudinous demands upon the academic surgeon, we all realize “too busy” is an answer synonomous with “I don’t care enough.” You, the university surgeon in the fullest sense, must never forget that our greatest organizational strengths mirror those personal qualities which have always identified the good doctor, skill, wisdom, and conscience. REFERENCES I. Anlyan, W. G. What the current medical student desires from the surgical faculty. Bull. Amer. Coil. Surg. Jul.-Aug.:7, 197 1. 2. Ballinger, W. F., and Collins, J. A. Integration of full-time and voluntary surgeons in a university hospital. Surgery 74:488, 1973. 3. Braunwald, E. Remarks made to Spring Meeting of Council of Academic Societies, Bethesda, Md., March 3, 1975. 4. Bricker, E. The private surgeon in a university hospital. Surgery 74~494, 1973. 5. Campbell, D. A. The measure of a surgeon. Arch. Surg. 110:464, 1975. 6. Cooper, J. A. D. President’s Report to the Association of American Medical Colleges, Washington, D.C., November, 1975. 7. Curreri, P. W., Zimmermann, C. E., Jaffe, B. M., Mackenzie, J. R., Nance, F. C., Zollinger, R., Jr., and Gardner, B. Survey of employment satisfaction in academic surgery./. Surg. Res. 17,215, 1974. 8. de Tocqueville, A. Democracy in America. New American Library of World Literature, New York, 1956. 9. Dunphy, J. E. Not from a curriculum. Amer. J. Surg. 116,408, 1968. 10. Eckert, C. Specialization and superspecialization in surgery. Arch. Surg. 109, 139, 1974. 11. Fein, R. Can the ‘doctor shortage’ be solved? Hosp. Pratt. Apr.:73, 1971. 12. Folkman, J. M. Don’t practice on me. Harvard Med. Alumni Bull. 49~39, 1975. 13. Fonkalsrud, E. W. Reassessment of surgical specialty training in the United States. Arch. Surg. 104:759, 1972. 14. Fonkalsrud, E. W. Too many medical society.meetings? Arch. Surg. 110:463, 1975. 15. Freiman, D. G. The curriculum revolution: Second thoughts. N. Engl. J. Med. 288:1240, 1973. 16. Goldhaber, S. 2. Medical education: Harvard reverts to tradition. Science 181:1027, 1973. 17. Hanlon, C. R. Discussion of DeWeese, J. A., Blais-
HIRAM C. POLK, JR.: PRESIDENTIAL dell, F. W., Foster, J. H., Optimal resources for vascular surgery. Arch. Surg. 105:948, 1972. 18. Johnston, J. H., Jr. The private surgeon looks at academia. Surgery 74:505,1973. 19. Kirkpatrick, J. J. The new national nightmare. Nation’s Business Aug.:ll, 1975. 20. Leape, L. L., Busby, D. D., Leming, J. C., Olson, M. I., and Humphrey, L. J. Who pays for medical education?Surgery 72:16, 1972. 21. Maloney, J. V., Jr. A report on the role of economic motivation in the performance of medical school faculty. Surgery 68:1, 1970. 22. Maloney, J. V., Jr. Doctors, dollars, and social unrest. Surg. Gynecol. Obstet. 132:492, 1971. 23. Medawar, P. B. Some follies of prediction. Hosp. Pratt. Apr.:73, 1975. 24. Moore, F. D. University in American surgery. Surgery 44:1, 1958. 25. Moore, F. D. Surgical teaching in the development of clinical competence. J. Amer. Med. Ass. 202:122, 1967. 26. Orloff, M. J. The university department of surgery: Its structure and role in American medicine. Surgery 72:1, 1972. 27. Parsons, T., and Platt, G. M. The American University. Harvard University Press, Cambridge,
Mass., 1973. 28. Richardson, E. L. We cannot strive for anything less. Bull. Amer. Coil. Surg. Jan.:17, 1971.
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29. Richardson, E. L. Shattuck Lecture-“The old order changeth, yielding place to new.” Perspectives on the health “revolution.” N. Engl. J. Med. 291:283,1974. 30. Schwartz, H. The Case for American Medicine. A Realistic Look aI Our Health Care System. David
McKay, New York, 1972. 31. Spodick, D. H. Numerators without denominators: There is no FDA for the surgeon. J. Amer. Med. Ass. 232:35, 1975.
32. Thomas, L. The Lives of a Cell. Viking Press, New York, 1974. 33. Varco, R. Recertification and subcertification. Paper presented at the Clinical Congress at the A.C.S., San Francisco, Calif., Oct. 15, 1975. 34. Wangensteen, 0. Historical aspects of some surgical training programs: A plea to retain the surgical generalist in the academic arena. Surgery 72:692, 1972. 35. Williams, G. Quality versus quantity in American
medical education. Science 153~956,1966. 36. Woodhall, B. The place of the medical school in the university. S. Med. J. 64:259, 1971. 37. Zeppa, R. Remarks to the American Surgical Association. Colorado Springs, Colo., May 2, 1974. 38. Zuidema, G. D. (Director). Surgery in the United States. A Summary Reporr of ihe Study on Surgical Services for the United Slates. The American
College of Surgeons and The American Surgical Association, 1975.
