- Email: [email protected]
Imperatives
American Journal of Obstetrics and Gynecology (2005) 192, 1483–7
www.ajog.org
Imperatives Michael P. Aronson, MD* From the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Mass Received for publication November 29, 2004; accepted January 20, 2005
Members of the American Urogynecologic Society, members of the Society of Gynecologic Surgeons and guests, I am very honored to address the historic first Joint Annual Scientific Meeting of these 2 great societies. A presidential address is a unique opportunity to discuss topics of a more personal or philosophic nature. Although this is my AUGS presidential address, I hope that you will feel that what we discuss applies to all of us: in both societies, in our subspecialty, and in our profession. I would like to speak with you about imperatives: the forces within each of as individuals, and within all of us collectively as a subspecialty and as a society that drive our actions overtly and covertly every day. The American Heritage Dictionary defines an imperative as ‘‘a rule, principle, or instinct that compels a certain behavior.’’ The imperatives we are talking about are not the rules of the American Urogynecologic Society or even the rules of our American society. The imperatives we are discussing today are those rules that we each make for ourselves. These are our internal rules that compel our behaviors. What are these guiding imperatives and how do we reconcile them when they are in conflict? We are conscious of some imperatives and we are not conscious of others, but, nevertheless, they drive each and every decision that we make. Sometimes our internal imperatives may be contradictory, and we must resolve that Twenty-fifth Presidential Address of the American Urogynecologic Society, delivered at The Joint Annual Scientific Meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons, San Diego, Calif, July 2004. * Reprint requests: Michael P. Aronson, MD, Department of Obstetrics and Gynecology, University of Massachusetts Medical School, 119 Belmont Street, Memorial Campus, Jaquith 4, Worcester, MA 01605-2982. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2005.01.052
conflict to come to a decision. How we each balance our imperatives determines the actions we take and, to a large extent, who we are. There are multiple imperatives that drive us: altruistic, economic, and personal (Figure). At all times we must strive to keep these in balance. As health care providers entrusted with the care and well-being of our patients, we would hope that altruism is the main imperative driving us. We have all chosen this profession because we wanted to help make our patients’ lives a little bit better by decreasing their suffering and improving the quality of their lives. When we are successful at this, we receive what I have always called ‘‘the second paycheck.’’ We get 1 paycheck to pay our rent, put food on our tables, and build college funds. Yet we get something more when we have done an operation and the patient returns with a smile wearing a new dress. She tells you she is happy because she is now taking her daily morning walk againdsomething she has not been able to do in years. She says, ‘‘Thank you very much, doctor.’’ That is the second paycheck. When I think of the altruistic imperative, a quote from Dr William Mayo comes to mind. Nearly 100 years ago he said, ‘‘The interests of the patient are the only interests to be considered.’’ This straightforward statement really says it all about the altruistic imperative. However, within it is the clear implication that there are other interests that might be considered. Even Dr. Mayo had rent to pay, had a family to feed, and had an institution to build; yet he understood clearly that service to the patient must be the central focus of his professional life. This altruistic imperative helped make him a unique physician and enabled him to do great things. An imperative by itself is not inherently good or bad. In fact, all imperatives have the potential to be positive
1484
Figure Multiple interdependent, and sometimes conflicting, imperatives consciously and subconsciously drive individual and societal decisions every day.
forces if they are kept in balance and perspective. It is when 1 imperative becomes out of balance with others that our judgment can become clouded. For example, we all certainly have economic imperatives. One does have to provide for one’s family today and for the future. One does have to provide for one’s practice, private or academic, so that it remains fiscally vibrant, allowing those who practice within it to continue their work. But at times enticements present themselves that go far beyond these considerations. It is then that the economic imperative can become out of balance with other imperatives and our judgment can become clouded. We also must remember that not all of economics is measured in dollars. Many in this room are in the academic world where there are other coins of the realm. The drive to do well academically, to do excellent research, and to be promoted in a timely fashion must be kept in balance as well. It would be too simplistic to say that our internal equation is just about altruism and economics and the balance between the 2. There are other imperatives at work every day in each and every one of us. These are personal imperatives. They are harder for each of us to see and often difficult for us to acknowledge. One’s persona is an important personal imperative. In our society, we tend to feel that ‘‘what you do is what you are.’’ Of course, this is not true. What you are, and who you are, is so much more than what you do.
Aronson Yet we do tend to define ourselves by what we do. Yesterday during our audience response session, 64% of us said that we were urogynecologists and 30% said we were ob-gyns. It is certainly appropriate that we feel proud of what we do and how we do it. But this can also get out of perspective. If a physician begins to feel that what he or she does really is what he or she is, that physician may be tempted to go beyond striving for excellence, beyond the point of balance, and beyond good judgment. The drive to be the one who does the biggest, who does the most daring, who does it fastest, and who does it first must be kept in balance with the best interests of our patients. The question must always be should one do it, not can one do it. You are so much more than what you do. Next is the inbred need for all humans to innovate and create. We need to solve problems and we need to improve things. This desire can be a very good thing or it too can get out of balance. Our J. Marion Sims Lecturer at this meeting Dr A. R. B. Smith, director of the Warrell Unit at St. Mary’s Hospital in Manchester, England, spoke of the challenges facing surgical innovation. He spoke about Dr. Sims who, in a different era some 150 years ago, pursued a surgical cure for vesicovaginal fistula by performing 40 operations on 3 slave women in a building that he had built for them in his backyard. Dr. J. Marion Sims was certainly one of our legendary, pioneering surgeons who gave us many things, including techniques for fistula repair, but clearly the imperative for innovation, creation, and solving problems was a dominant force in his life, perhaps even a force out of balance by today’s standards. The human need to innovate and create is a positive force in our specialty and is, and will continue to be, largely responsible for many advances that benefit our patients. It drives us to develop new techniques and to improve our treatments, but it can also go beyond that. We must not be lured by the dictum, ‘‘If you can think it, you can do it.’’ The Annals of the Royal College of Surgeons from 1950 includes the statement, ‘‘The feasibility of an operation is not the best indication for its performance.’’ The efficacy, safety, and benefit to the patient must remain the best indications for any procedure. We are all surgeons in this room . and surgeons do like to operate. This, in and of itself, is a human trait. Humans like to perform procedures and there is actually a word for it: ‘‘funktionslust.’’ First described in the 1930s by the German psychiatrist Karl Bu¨hler and popularized in the 1980s by the Nobel Prizeewinning behavioralist Konrad Lorenz, funktionslust is defined as ‘‘joy and pride from performing a skill well.’’ This is a good thing. This is what helps the bricklayer go to work every day for 30 years; knowing that he or she lays bricks very well, and just doing that brings a sense of joy and pride. The more complicated the task, the more joy and pride is felt.
Aronson Research shows that a primate confronted with a complicated locking mechanism on a box containing a food treat will learn how to master opening that mechanism. Even if the food is no longer put inside, the primate will continue to repeatedly unlock that mechanism. The act of performing the procedure becomes its own reward. Funktionslustdjoy and pride from performing a skill welldis an important and positive imperative felt by all humans. Is there a single surgeon in this room who does not feel some sense of joy and pride about how they perform their procedures? But this imperative can also grow in importance and destroy our sense of balance. If the desire to perform a procedure because we perform it well overcomes other considerations, our judgment can most certainly become clouded. Our multiple imperatives (altruistic, economic, and personal) can all be positive forces if kept in balance with each other. Balance is crucial. Balance is the key. So what about societies? It is most impressive that the American Urogynecologic Society has now been an organization for 25 years. This year AUGS is blessed to meet together with the Society of Gynecologic Surgeons, which has been an organization for 30 years. We in the field of urogynecology and reconstructive pelvic surgery have accomplished a great deal, and we have gone far. But in actuality we are only at the beginning. This year the national society for our colleagues in reproductive endocrinology, the American Society for Reproductive Medicine, is celebrating its 60th year. Thirty years ago they were where we are now. In fact, it was about 30 years ago that our subspecialties in gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology were formally approved. Preparing for this address, I had the pleasure of speaking with a number of individuals who were involved in that process. Just imagine the time: Richard Nixon is president, the American Board of Obstetrics and Gynecology thinks that creating these 3 subspecialties is a great idea, segments of the general surgery community are not so sure, and the American College of Obstetricians and Gynecologists is pretty certain that it is a bad idea. Except for President Nixon, does this sound at all familiar? One could make the case that we in our subspecialty are precisely where our colleagues were in their development 30 years ago. If so, what are we going to do over the coming 30 years? In a nutshell, we have to learn how to do what we do better. At this meeting our State-of-the-Art lecturer, Dr Duane Alexander, director of the National Institute of Child Health and Human Development at the National Institutes of Health, told us that before 1997 there was no activity at the National Institutes of Health around issues of the female pelvic floor. Seven years later we have 2 National Institutes of Healthefunded multicenter networks focused specifically on these problems as well as other significant granting activity. We are off to
1485 an excellent start. Can we mature and expand this support for research in our field over the coming 30 years? Can we refine, nurture, and grow our networks to yield decades of productive work? I don’t see why not. At this meeting our Richard W. TeLinde lecturer, Dr Shukri Khuri, chief of surgical services and chief of cardiothoracic surgery at the Brockton-West Roxbury Veterans Affairs Medical Center, told us about the extraordinary evidence-based work that the Veteran’s Affairs system has done to understand outcomes and attempt to improve them through the analysis of extensive databases. Can we do the same in the field of urogynecology/reconstructive pelvic surgery over the coming 30 years? I don’t see why not. Yesterday Dr John Delancey in his Society of Gynecologic Surgeons Presidential Address outlined very elegantly how, through research and improved understanding of our basic disease processes, we can move toward achieving a 25% reduction in pelvic floor injuries and a 25% improvement in treatment of pelvic floor dysfunction. We have 30 years; do you think we can do that? I don’t see why not. But to accomplish all this, we are all going to have to deal with imperatives as individuals, as a society, and as a subspecialty. Societies collectively have their own internalized imperatives: economic, personal, and altruistic. In my time working for the American Urogynecologic Society, I have been impressed with how the membership and leadership of the organization are dealing with societal imperatives. We have economic imperatives in both our society and in our specialty. We are terribly underreimbursed for what we do. It is not right or reasonable to expect a surgeon to perform complex, challenging, and lengthy operations and be reimbursed the same or less than another surgeon is reimbursed for performing shorter and simpler procedures. The Coding Committee of the American Urogynecologic Society has had tremendous success this year in facilitating the creation of fairer codes for many of our procedures and more accurate codes for many of our diagnoses. AUGS is now taking the important step of forming an industry liaison council. We must find an honest and beneficial way to coexist with our industry partners based on mutual respect. This is, by definition, a difficult relationship. As physicians and health care providers, our first allegiance must always be to the patient. However, it is important for us to understand, accept, and respect that in the corporate world, first allegiance is to the shareholder and therefore to the bottom line. This is not inherently a bad thing; it is reality. If we are able to reach a place where we as providers accept and respect the imperatives that drive industry and our industry partners accept and respect that our allegiance must always be to the interests of the patient, I believe that we can find a common ground that is beneficial for everyone. This can be accomplished only with true transparency.
1486 That is why AUGS is forming an industry liaison council, a place where all can come together in the light of day and openly discuss ways to achieve mutually beneficial goals. The American Urogynecologic Society and our specialty also have personal imperatives. A society’s ‘‘personal’’ imperatives are summations of all of us who are members. This makes them quite complex. Think about it. There are almost 1000 people in this room right now. Every one of you is an individual who has a favorite color, a lucky number, foods you like to eat, and foods you do not like to eat. You each have feelings about who you are, what you do, a certain degree of funktionslust, and a need to innovate and create. You each have economic interests and you each feel altruistic imperatives. If you multiply each of these complex individuals by 1000, the size of our membership today, that is the American Urogynecologic Society’s collective personal imperative. This is a complex set of imperatives to know and to understand. Over the past year, AUGS has made tremendous strides toward understanding its membership and becoming more responsive to its members’ needs. For the second year in a row at our annual meeting, we have had the beginnings of a dialog via an audience response system. We have also begun to use short, Web-based questionnaires to better understand who our membership is and to allow more of the membership to be involved in future planning. These are examples of the kind of 2-way communication that we will need in the future. Who are we, and where do we all want to go? It is hard to know that, but we are working on it. In October 2004, AUGS will have its first strategic planning retreat. Most societies of our size and age do this every 3 years. AUGS has passed a resolution that our strategic plan will be reviewed every year and that an AUGS Strategic Planning Retreat will take place every 3 years. All aspects of our society will be represented at this initial retreat: general membership, fellows, executive committee, and board of directors. Participants were recruited from the entire membership. Thirty-one individuals applied on-line and participants were chosen in a blinded fashion. The important concept is to involve as broad a cross-section of our society as possible in the discussion of where we are going to go and how we are going to get there. Most importantly, in the American Urogynecologic Society and in our specialty, we have altruistic imperatives. Altruism is the major imperative of the American Urogynecologic Society: It is really what we are all about. Altruism is the force that drives the fabulous work done by our Research Committee, Education Committee, Public Relations Committee, and Government Relations Committee. All year long dozens of individuals selflessly put in countless volunteer hours and days of effort through our organization. This work is certainly driven by many imperatives, but in the end it is all focused on advancing the interests of our patients.
Aronson I would like to take a few minutes now to thank some people. As I look out on this audience, I can easily see more than a hundred individuals that have mentored me over the years and made me a better person. It may have been in a direct teaching role, it may have been by example, or it may have been by drawing some anatomic structure on a napkin at the Acme Oyster House in New Orleans. In one way or another, so many of you have helped me to become better than I was before I met you. I thank all of you for that. There are a few individuals about whom I would like to say an additional word. Some of them you know and some of them you do not know. First, I would like to thank Dr Philip P. McGovern, Jr. Dr McGovern, a beloved private practitioner in the Tufts system in Boston, was my first mentor in obstetrics and gynecology when I was a medical student. Dr McGovern taught me to be a good doctor and he taught me to be a good surgeon. He also taught me that it is not only acceptable but also important to have a social conscience and to incorporate it into how you conduct yourself personally and professionally. Dr McGovern worked for 35 years at Cambridge City Hospital caring for indigent women. When I asked his son Christopher to send some pictures of his father for this address, he remembered that when he was a boy, his dad came home one night troubled by problems in the neighborhood health clinics and wondering how he could solve them. He asked his father why he did not just open up a practice in the suburbs and take care of wealthy women to which his father replied, ‘‘Because they don’t need me . and who’s going to take care of the poor?’’ Christopher said that in that moment he knew his dad was someone special. He was right. Dr McGovern has a social conscience that he incorporates into his life, and he taught me to do the same. I thank him for that. I also thank Dr McGovern for having a friend in Providence, Rhode Island, who he thought I might benefit from knowing. During and after my residency, Dr David H. Nichols taught me to be a good doctor and he taught me to be a good surgeon. He also taught me that it is not only acceptable but also important to have a sense of historical perspective and to incorporate it into how you conduct yourself personally and professionally. Dr Nichols knew that there was nothing new under the sun. He knew that a hundred years ago very smart people were thinking about and working on many of the same concepts and problems that we are working on today. He recognized the value of learning from the past while contributing to the present to improve our understanding and our practice in the future. Dr Nichols taught me that we are all a part of this struggle to learn but that our time in that spectrum is short. Even if this ongoing struggle for knowledge was only 100 years long, at most we are each going to be part of it for maybe 20 or 30 years. That is humbling. It is healthy to be
Aronson humbled. Dr Nichols understood that to know where we are going, we need to know and understand where we have been. He incorporated that sensibility into his life, taught me to do the same, and I thank him for that. I also thank Dr Nichols for having a friend in Rochester, Minnesota, who he thought I might benefit from knowing. Dr Raymond A. Lee has taught me as a fellow, and continues to teach me today, to be a good doctor and a good surgeon. He also taught me that it is not only acceptable but also important to be human and to be humane and to incorporate this into how you conduct yourself personally and professionally. There is no more accomplished and famous pelvic surgeon in the world than Dr Raymond Lee. At the same time, there is not a more caring, giving, and genuine individual in the world than he. Dr Lee spent his entire professional life at a large, prestigious institution, yet I have observed that he values the contribution of every member of the team from the most powerful colleague to the individuals who clean his operating room and his office. It is clear from his actions that he just does not think that anyone was put on this planet to wait on him. Dr Lee has fully integrated who he is with what he does and has taught me to strive to do the same. He is one of the finest individuals I have ever known. I am lucky that he is my mentor. I am even luckier that he is my friend. I thank him for that. Of course, I would not have been able to understand or learn from any of this had it not been for the lifelong loving guidance and unparalleled example of my father and my mother, Ted and Gloria Aronson. My mom and
1487 dad came from very humble roots, and they never forgot that. They raised their children to believe that to ‘‘do the right thing’’ is not just an idea, but a credo by which to live your life. They taught me the value of striving to lead a good life and of helping to make the world a better place. I cannot ever thank them enough for that. Last, and most importantly, I want to thank the most significant obstetrician/gynecologist in my life, Dr Patricia K. Aronson. Pat has taught me everything else that I know! Her wisdom, her grace, and her love have helped me grow every day for 20 years and I thank her. And I am truly blessed because she also gave me 2 of the most excellent and outstanding young men that I have ever met, our sons Ted and Adam. I am blessed because I get to live and grow with these 3 wonderful people. They help me to keep my imperatives in focus and in balance every day. I thank all 3 of them for that. Our subspecialty has done much and we have come a long way, but we clearly still have a long way to go. Whatever we do and whatever we accomplish together over the next 30 years, I am quite certain of one thing: Embracing the struggle to understand and balance the imperatives that drive each of us individually, and all of us collectively, cannot help but make us better as individuals, and as a society, and move us toward our goals. I want to sincerely thank all of you for having given me the honor and the privilege of serving as president of the American Urogynecologic Society. Thank you.
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Imperatives Michael P. Aronson, MD* From the Department of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, Mass Received for publication November 29, 2004; accepted January 20, 2005
Members of the American Urogynecologic Society, members of the Society of Gynecologic Surgeons and guests, I am very honored to address the historic first Joint Annual Scientific Meeting of these 2 great societies. A presidential address is a unique opportunity to discuss topics of a more personal or philosophic nature. Although this is my AUGS presidential address, I hope that you will feel that what we discuss applies to all of us: in both societies, in our subspecialty, and in our profession. I would like to speak with you about imperatives: the forces within each of as individuals, and within all of us collectively as a subspecialty and as a society that drive our actions overtly and covertly every day. The American Heritage Dictionary defines an imperative as ‘‘a rule, principle, or instinct that compels a certain behavior.’’ The imperatives we are talking about are not the rules of the American Urogynecologic Society or even the rules of our American society. The imperatives we are discussing today are those rules that we each make for ourselves. These are our internal rules that compel our behaviors. What are these guiding imperatives and how do we reconcile them when they are in conflict? We are conscious of some imperatives and we are not conscious of others, but, nevertheless, they drive each and every decision that we make. Sometimes our internal imperatives may be contradictory, and we must resolve that Twenty-fifth Presidential Address of the American Urogynecologic Society, delivered at The Joint Annual Scientific Meeting of the American Urogynecologic Society and the Society of Gynecologic Surgeons, San Diego, Calif, July 2004. * Reprint requests: Michael P. Aronson, MD, Department of Obstetrics and Gynecology, University of Massachusetts Medical School, 119 Belmont Street, Memorial Campus, Jaquith 4, Worcester, MA 01605-2982. E-mail: [email protected] 0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2005.01.052
conflict to come to a decision. How we each balance our imperatives determines the actions we take and, to a large extent, who we are. There are multiple imperatives that drive us: altruistic, economic, and personal (Figure). At all times we must strive to keep these in balance. As health care providers entrusted with the care and well-being of our patients, we would hope that altruism is the main imperative driving us. We have all chosen this profession because we wanted to help make our patients’ lives a little bit better by decreasing their suffering and improving the quality of their lives. When we are successful at this, we receive what I have always called ‘‘the second paycheck.’’ We get 1 paycheck to pay our rent, put food on our tables, and build college funds. Yet we get something more when we have done an operation and the patient returns with a smile wearing a new dress. She tells you she is happy because she is now taking her daily morning walk againdsomething she has not been able to do in years. She says, ‘‘Thank you very much, doctor.’’ That is the second paycheck. When I think of the altruistic imperative, a quote from Dr William Mayo comes to mind. Nearly 100 years ago he said, ‘‘The interests of the patient are the only interests to be considered.’’ This straightforward statement really says it all about the altruistic imperative. However, within it is the clear implication that there are other interests that might be considered. Even Dr. Mayo had rent to pay, had a family to feed, and had an institution to build; yet he understood clearly that service to the patient must be the central focus of his professional life. This altruistic imperative helped make him a unique physician and enabled him to do great things. An imperative by itself is not inherently good or bad. In fact, all imperatives have the potential to be positive
1484
Figure Multiple interdependent, and sometimes conflicting, imperatives consciously and subconsciously drive individual and societal decisions every day.
forces if they are kept in balance and perspective. It is when 1 imperative becomes out of balance with others that our judgment can become clouded. For example, we all certainly have economic imperatives. One does have to provide for one’s family today and for the future. One does have to provide for one’s practice, private or academic, so that it remains fiscally vibrant, allowing those who practice within it to continue their work. But at times enticements present themselves that go far beyond these considerations. It is then that the economic imperative can become out of balance with other imperatives and our judgment can become clouded. We also must remember that not all of economics is measured in dollars. Many in this room are in the academic world where there are other coins of the realm. The drive to do well academically, to do excellent research, and to be promoted in a timely fashion must be kept in balance as well. It would be too simplistic to say that our internal equation is just about altruism and economics and the balance between the 2. There are other imperatives at work every day in each and every one of us. These are personal imperatives. They are harder for each of us to see and often difficult for us to acknowledge. One’s persona is an important personal imperative. In our society, we tend to feel that ‘‘what you do is what you are.’’ Of course, this is not true. What you are, and who you are, is so much more than what you do.
Aronson Yet we do tend to define ourselves by what we do. Yesterday during our audience response session, 64% of us said that we were urogynecologists and 30% said we were ob-gyns. It is certainly appropriate that we feel proud of what we do and how we do it. But this can also get out of perspective. If a physician begins to feel that what he or she does really is what he or she is, that physician may be tempted to go beyond striving for excellence, beyond the point of balance, and beyond good judgment. The drive to be the one who does the biggest, who does the most daring, who does it fastest, and who does it first must be kept in balance with the best interests of our patients. The question must always be should one do it, not can one do it. You are so much more than what you do. Next is the inbred need for all humans to innovate and create. We need to solve problems and we need to improve things. This desire can be a very good thing or it too can get out of balance. Our J. Marion Sims Lecturer at this meeting Dr A. R. B. Smith, director of the Warrell Unit at St. Mary’s Hospital in Manchester, England, spoke of the challenges facing surgical innovation. He spoke about Dr. Sims who, in a different era some 150 years ago, pursued a surgical cure for vesicovaginal fistula by performing 40 operations on 3 slave women in a building that he had built for them in his backyard. Dr. J. Marion Sims was certainly one of our legendary, pioneering surgeons who gave us many things, including techniques for fistula repair, but clearly the imperative for innovation, creation, and solving problems was a dominant force in his life, perhaps even a force out of balance by today’s standards. The human need to innovate and create is a positive force in our specialty and is, and will continue to be, largely responsible for many advances that benefit our patients. It drives us to develop new techniques and to improve our treatments, but it can also go beyond that. We must not be lured by the dictum, ‘‘If you can think it, you can do it.’’ The Annals of the Royal College of Surgeons from 1950 includes the statement, ‘‘The feasibility of an operation is not the best indication for its performance.’’ The efficacy, safety, and benefit to the patient must remain the best indications for any procedure. We are all surgeons in this room . and surgeons do like to operate. This, in and of itself, is a human trait. Humans like to perform procedures and there is actually a word for it: ‘‘funktionslust.’’ First described in the 1930s by the German psychiatrist Karl Bu¨hler and popularized in the 1980s by the Nobel Prizeewinning behavioralist Konrad Lorenz, funktionslust is defined as ‘‘joy and pride from performing a skill well.’’ This is a good thing. This is what helps the bricklayer go to work every day for 30 years; knowing that he or she lays bricks very well, and just doing that brings a sense of joy and pride. The more complicated the task, the more joy and pride is felt.
Aronson Research shows that a primate confronted with a complicated locking mechanism on a box containing a food treat will learn how to master opening that mechanism. Even if the food is no longer put inside, the primate will continue to repeatedly unlock that mechanism. The act of performing the procedure becomes its own reward. Funktionslustdjoy and pride from performing a skill welldis an important and positive imperative felt by all humans. Is there a single surgeon in this room who does not feel some sense of joy and pride about how they perform their procedures? But this imperative can also grow in importance and destroy our sense of balance. If the desire to perform a procedure because we perform it well overcomes other considerations, our judgment can most certainly become clouded. Our multiple imperatives (altruistic, economic, and personal) can all be positive forces if kept in balance with each other. Balance is crucial. Balance is the key. So what about societies? It is most impressive that the American Urogynecologic Society has now been an organization for 25 years. This year AUGS is blessed to meet together with the Society of Gynecologic Surgeons, which has been an organization for 30 years. We in the field of urogynecology and reconstructive pelvic surgery have accomplished a great deal, and we have gone far. But in actuality we are only at the beginning. This year the national society for our colleagues in reproductive endocrinology, the American Society for Reproductive Medicine, is celebrating its 60th year. Thirty years ago they were where we are now. In fact, it was about 30 years ago that our subspecialties in gynecologic oncology, maternal-fetal medicine, and reproductive endocrinology were formally approved. Preparing for this address, I had the pleasure of speaking with a number of individuals who were involved in that process. Just imagine the time: Richard Nixon is president, the American Board of Obstetrics and Gynecology thinks that creating these 3 subspecialties is a great idea, segments of the general surgery community are not so sure, and the American College of Obstetricians and Gynecologists is pretty certain that it is a bad idea. Except for President Nixon, does this sound at all familiar? One could make the case that we in our subspecialty are precisely where our colleagues were in their development 30 years ago. If so, what are we going to do over the coming 30 years? In a nutshell, we have to learn how to do what we do better. At this meeting our State-of-the-Art lecturer, Dr Duane Alexander, director of the National Institute of Child Health and Human Development at the National Institutes of Health, told us that before 1997 there was no activity at the National Institutes of Health around issues of the female pelvic floor. Seven years later we have 2 National Institutes of Healthefunded multicenter networks focused specifically on these problems as well as other significant granting activity. We are off to
1485 an excellent start. Can we mature and expand this support for research in our field over the coming 30 years? Can we refine, nurture, and grow our networks to yield decades of productive work? I don’t see why not. At this meeting our Richard W. TeLinde lecturer, Dr Shukri Khuri, chief of surgical services and chief of cardiothoracic surgery at the Brockton-West Roxbury Veterans Affairs Medical Center, told us about the extraordinary evidence-based work that the Veteran’s Affairs system has done to understand outcomes and attempt to improve them through the analysis of extensive databases. Can we do the same in the field of urogynecology/reconstructive pelvic surgery over the coming 30 years? I don’t see why not. Yesterday Dr John Delancey in his Society of Gynecologic Surgeons Presidential Address outlined very elegantly how, through research and improved understanding of our basic disease processes, we can move toward achieving a 25% reduction in pelvic floor injuries and a 25% improvement in treatment of pelvic floor dysfunction. We have 30 years; do you think we can do that? I don’t see why not. But to accomplish all this, we are all going to have to deal with imperatives as individuals, as a society, and as a subspecialty. Societies collectively have their own internalized imperatives: economic, personal, and altruistic. In my time working for the American Urogynecologic Society, I have been impressed with how the membership and leadership of the organization are dealing with societal imperatives. We have economic imperatives in both our society and in our specialty. We are terribly underreimbursed for what we do. It is not right or reasonable to expect a surgeon to perform complex, challenging, and lengthy operations and be reimbursed the same or less than another surgeon is reimbursed for performing shorter and simpler procedures. The Coding Committee of the American Urogynecologic Society has had tremendous success this year in facilitating the creation of fairer codes for many of our procedures and more accurate codes for many of our diagnoses. AUGS is now taking the important step of forming an industry liaison council. We must find an honest and beneficial way to coexist with our industry partners based on mutual respect. This is, by definition, a difficult relationship. As physicians and health care providers, our first allegiance must always be to the patient. However, it is important for us to understand, accept, and respect that in the corporate world, first allegiance is to the shareholder and therefore to the bottom line. This is not inherently a bad thing; it is reality. If we are able to reach a place where we as providers accept and respect the imperatives that drive industry and our industry partners accept and respect that our allegiance must always be to the interests of the patient, I believe that we can find a common ground that is beneficial for everyone. This can be accomplished only with true transparency.
1486 That is why AUGS is forming an industry liaison council, a place where all can come together in the light of day and openly discuss ways to achieve mutually beneficial goals. The American Urogynecologic Society and our specialty also have personal imperatives. A society’s ‘‘personal’’ imperatives are summations of all of us who are members. This makes them quite complex. Think about it. There are almost 1000 people in this room right now. Every one of you is an individual who has a favorite color, a lucky number, foods you like to eat, and foods you do not like to eat. You each have feelings about who you are, what you do, a certain degree of funktionslust, and a need to innovate and create. You each have economic interests and you each feel altruistic imperatives. If you multiply each of these complex individuals by 1000, the size of our membership today, that is the American Urogynecologic Society’s collective personal imperative. This is a complex set of imperatives to know and to understand. Over the past year, AUGS has made tremendous strides toward understanding its membership and becoming more responsive to its members’ needs. For the second year in a row at our annual meeting, we have had the beginnings of a dialog via an audience response system. We have also begun to use short, Web-based questionnaires to better understand who our membership is and to allow more of the membership to be involved in future planning. These are examples of the kind of 2-way communication that we will need in the future. Who are we, and where do we all want to go? It is hard to know that, but we are working on it. In October 2004, AUGS will have its first strategic planning retreat. Most societies of our size and age do this every 3 years. AUGS has passed a resolution that our strategic plan will be reviewed every year and that an AUGS Strategic Planning Retreat will take place every 3 years. All aspects of our society will be represented at this initial retreat: general membership, fellows, executive committee, and board of directors. Participants were recruited from the entire membership. Thirty-one individuals applied on-line and participants were chosen in a blinded fashion. The important concept is to involve as broad a cross-section of our society as possible in the discussion of where we are going to go and how we are going to get there. Most importantly, in the American Urogynecologic Society and in our specialty, we have altruistic imperatives. Altruism is the major imperative of the American Urogynecologic Society: It is really what we are all about. Altruism is the force that drives the fabulous work done by our Research Committee, Education Committee, Public Relations Committee, and Government Relations Committee. All year long dozens of individuals selflessly put in countless volunteer hours and days of effort through our organization. This work is certainly driven by many imperatives, but in the end it is all focused on advancing the interests of our patients.
Aronson I would like to take a few minutes now to thank some people. As I look out on this audience, I can easily see more than a hundred individuals that have mentored me over the years and made me a better person. It may have been in a direct teaching role, it may have been by example, or it may have been by drawing some anatomic structure on a napkin at the Acme Oyster House in New Orleans. In one way or another, so many of you have helped me to become better than I was before I met you. I thank all of you for that. There are a few individuals about whom I would like to say an additional word. Some of them you know and some of them you do not know. First, I would like to thank Dr Philip P. McGovern, Jr. Dr McGovern, a beloved private practitioner in the Tufts system in Boston, was my first mentor in obstetrics and gynecology when I was a medical student. Dr McGovern taught me to be a good doctor and he taught me to be a good surgeon. He also taught me that it is not only acceptable but also important to have a social conscience and to incorporate it into how you conduct yourself personally and professionally. Dr McGovern worked for 35 years at Cambridge City Hospital caring for indigent women. When I asked his son Christopher to send some pictures of his father for this address, he remembered that when he was a boy, his dad came home one night troubled by problems in the neighborhood health clinics and wondering how he could solve them. He asked his father why he did not just open up a practice in the suburbs and take care of wealthy women to which his father replied, ‘‘Because they don’t need me . and who’s going to take care of the poor?’’ Christopher said that in that moment he knew his dad was someone special. He was right. Dr McGovern has a social conscience that he incorporates into his life, and he taught me to do the same. I thank him for that. I also thank Dr McGovern for having a friend in Providence, Rhode Island, who he thought I might benefit from knowing. During and after my residency, Dr David H. Nichols taught me to be a good doctor and he taught me to be a good surgeon. He also taught me that it is not only acceptable but also important to have a sense of historical perspective and to incorporate it into how you conduct yourself personally and professionally. Dr Nichols knew that there was nothing new under the sun. He knew that a hundred years ago very smart people were thinking about and working on many of the same concepts and problems that we are working on today. He recognized the value of learning from the past while contributing to the present to improve our understanding and our practice in the future. Dr Nichols taught me that we are all a part of this struggle to learn but that our time in that spectrum is short. Even if this ongoing struggle for knowledge was only 100 years long, at most we are each going to be part of it for maybe 20 or 30 years. That is humbling. It is healthy to be
Aronson humbled. Dr Nichols understood that to know where we are going, we need to know and understand where we have been. He incorporated that sensibility into his life, taught me to do the same, and I thank him for that. I also thank Dr Nichols for having a friend in Rochester, Minnesota, who he thought I might benefit from knowing. Dr Raymond A. Lee has taught me as a fellow, and continues to teach me today, to be a good doctor and a good surgeon. He also taught me that it is not only acceptable but also important to be human and to be humane and to incorporate this into how you conduct yourself personally and professionally. There is no more accomplished and famous pelvic surgeon in the world than Dr Raymond Lee. At the same time, there is not a more caring, giving, and genuine individual in the world than he. Dr Lee spent his entire professional life at a large, prestigious institution, yet I have observed that he values the contribution of every member of the team from the most powerful colleague to the individuals who clean his operating room and his office. It is clear from his actions that he just does not think that anyone was put on this planet to wait on him. Dr Lee has fully integrated who he is with what he does and has taught me to strive to do the same. He is one of the finest individuals I have ever known. I am lucky that he is my mentor. I am even luckier that he is my friend. I thank him for that. Of course, I would not have been able to understand or learn from any of this had it not been for the lifelong loving guidance and unparalleled example of my father and my mother, Ted and Gloria Aronson. My mom and
1487 dad came from very humble roots, and they never forgot that. They raised their children to believe that to ‘‘do the right thing’’ is not just an idea, but a credo by which to live your life. They taught me the value of striving to lead a good life and of helping to make the world a better place. I cannot ever thank them enough for that. Last, and most importantly, I want to thank the most significant obstetrician/gynecologist in my life, Dr Patricia K. Aronson. Pat has taught me everything else that I know! Her wisdom, her grace, and her love have helped me grow every day for 20 years and I thank her. And I am truly blessed because she also gave me 2 of the most excellent and outstanding young men that I have ever met, our sons Ted and Adam. I am blessed because I get to live and grow with these 3 wonderful people. They help me to keep my imperatives in focus and in balance every day. I thank all 3 of them for that. Our subspecialty has done much and we have come a long way, but we clearly still have a long way to go. Whatever we do and whatever we accomplish together over the next 30 years, I am quite certain of one thing: Embracing the struggle to understand and balance the imperatives that drive each of us individually, and all of us collectively, cannot help but make us better as individuals, and as a society, and move us toward our goals. I want to sincerely thank all of you for having given me the honor and the privilege of serving as president of the American Urogynecologic Society. Thank you.