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Presidential address: Evolution
Volume 128
Number 2
SURGERY AUGUST
2000
Society of University Surgeons Presidential address: Evolution R. Daniel Beauchamp, MD, Nashville, Tenn
From the Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tenn
IT HAS BEEN MY GREAT HONOR and privilege to serve as the president of the Society of University Surgeons for the past year and to have served on the Executive Council for a total of 5 years. I wish to thank you for the opportunity that you have given me to serve this society and to address you on this the 61st annual SUS meeting. In keeping with tradition, I sought inspiration for this address by reviewing countless prior published presidential addresses. I took some measure of comfort in this task from the realization that many have tread similar ground in the past and have survived to tell about it. My anticipation of this event was similar to that expressed by Seymour I. Schwartz1 in his 1994 Presidential Address to the American Surgical Association. He said, “The past year has also been characterized by recurrent anxiety related to the preparation of an address that is inevitably exposed to comparison and criticism but, fortunately, is rarely remembered by the audience.” Perhaps the best advice I received regarding the preparation of this address was from my mother. She advised me to keep it brief. She said, “You know how it feels to sit through one of those longwinded speeches.” Presented at the 61st Annual Meeting of the Society of University Surgeons, Toronto, Ontario, Canada, February 1012, 2000. Reprint requests: Daniel Beauchamp, MD, Department of Surgery, Vanderbilt University School of Medicine, 21st Ave S, MCN D5230, Nashville, TN 37232-2729. Surgery 2000;128:123-32 Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0 doi:10.1067/msy.2000.108057
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Before I proceed with my address, I first want to publicly recognize and thank several important people in my life. First and foremost I want to thank my wife, Shannon, and our daughter, Bryn, for their love and support. I also wish to thank them for their tolerance of the selfish pursuits inherent in this career. They have taught me the most important treasures of this life. I also wish to recognize and thank several people who have been kind enough to serve as mentors to me over the past 20 years. Courtney M. Townsend, Jr and James C. Thompson have both served as my role models as surgeon scientists. Jim Thompson (Fig 1) was the Chairman of Surgery during my residency and was my first boss as a junior faculty member at the University of Texas Medical Branch in Galveston. Jim is the Ashbel Smith Distinguished Professor at UTMB and is currently the President of the American College of Surgeons. Courtney Townsend (Fig 2) has been my mentor since my first clinical clerkship in surgery as a third-year medical student, and he remains a valued scientific and surgical mentor. Courtney is currently Chairman of Surgery at UTMB. I was fortunate enough to have been educated and to have received my surgical and initial scientific training working with these two men who are truly University Surgeons in every respect. With these two as role models, it never occurred to me to question whether one could simultaneously be an excellent clinical surgeon, a successful scientific investigator, a dedicated educator, and an effective administrator. I now realize the degree of difficulty involved in balancing these very different SURGERY 123
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Fig 1. James C. Thompson, MD, former chairman of the Department of Surgery at the University of Texas Medical Branch.
aspects of a career as a surgical leader. I continue to seek their counsel on a regular basis. I also wish to thank another of my mentors, Harold Moses (Fig 3), who is currently the Director of the Vanderbilt-Ingram Cancer Center. Hal took a chance in inviting a young surgeon to be a postdoctoral fellow in his cell biology laboratory at Vanderbilt in 1987. Hal was also instrumental in my returning to Vanderbilt in 1994 to join in his efforts to build scientific and clinical programs in the new cancer center. I continue to learn a great deal about both science and organizational management by working with Hal in the Vanderbilt-Ingram Cancer Center. I wish to recognize and thank James A. O’Neill, Jr (Fig 4), the Chairman of Surgery at Vanderbilt University Medical Center. Jim became Chairman of Surgery at about the same time that I moved back to Nashville at the end of 1994. I could not have asked for a more fair and supportive chairman. Both Jim O’Neill and my previous chairman Jim Thompson have been outstanding in their attention to detail in the development of young faculty members. Jim O’Neill is my role model for a leadership style characterized by equanimity, and I am fortunate to work under his guidance. Finally, I wish to thank all of my colleagues, the residents, fellows, students, and patients at the Vanderbilt University Medical Center for making it fun to come to work every day. This talk is entitled “Evolution.” The first definition of evolution in Webster’s dictionary is “a gradual process in which something changes into a sig-
Fig 2. Courtney M. Townsend, MD, current chairman of the Department of Surgery at the University of Texas Medical Branch.
nificantly different, especially more complex or more sophisticated, form.” This applies to biological systems, to societies, and to organizations. I want to briefly discuss the evolution that we are experiencing in the broad field of medicine and how it relates to us in the specific arena of academic surgery. Like Darwin’s finches, we must evolve in order to adapt to our world lest we face extinction. It is vital that the rising leaders in academic surgery, largely comprised of members of the Society of University Surgeons, are prepared to evolve so that we may adequately adapt to the needs of our patients and to the educational and training requirements of the next generations of surgeons. We also must adapt in order to continue to make scientific contributions aimed at improving our understanding and treatment of the diseases that we confront. The tide of evolution carries everything before it, thoughts no less than bodies, and persons no less than nations. —George Santayana Little Essays (1920)2
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Fig 4. James A. O’Neill, Jr, MD, chairman of the Department of Surgery at the Vanderbilt University School of Medicine. Fig 3. Harold L. Moses, MD, director of the VanderbiltIngram Cancer Center at the Vanderbilt University School of Medicine.
We need no better indication of the changes that will occur in our profession over the next century than to briefly ponder some of the remarkable changes that have occurred over the past century. At the beginning of the 20th century, one would have had to travel several days, if not weeks, to attend this meeting. Travel to work was mostly by foot, horseback, or horse-drawn carriage; and house calls by a horse-mounted physician who concocted his own medications carried in a saddlebag were not uncommon. Yet the automobile had already been invented in Germany, and the assembly lines engineered by Henry Ford were soon to make it affordable for the masses. The Wright brothers were preparing for their first historic flight that would lead in only a few decades to commercial airline transportation that has largely supplanted rail, buses, and ships for long-distance transportation. The application of electric energy in every facet of life would dramatically change the ways we worked and lived and would extend the potential period of human productivity from
around 12 hours to 24 hours per day. During the 20th century, the telephone, radio, television, and finally the computer would revolutionize our method of communication. Current information technology, the Internet, and affordable air travel have continued to revolutionize communication and have made the world a much smaller place in which to live. At the turn of the 20th century, the field of medicine was also poised to make numerous rapid advances.3 A century before, Edward Jenner had already established the concept of infectious disease prevention in his famous 1798 paper describing a successful technique of inoculating humans with fluid from the sores of vaccinia, or cowpox, to prevent infection with smallpox, the single most deadly infectious killer of that period. Jenner’s remarkable observations were not immediately accepted by the general public as one may see in a cartoon from that era depicting potential complications after inoculation with the cowpox vaccine (Fig 5). Pioneering work by many other investigators including Louis Pasteur, Robert Koch, and many others working in the 18th and 19th centuries led
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Fig 5. James Gillray’s The Cow-Pock-or-the wonderful effects of the new inoculation! (1802). (Courtesy of the National Library of Medicine, Bethesda.)
Table I. Changes in life expectancy 1900
1997
87.6% of infants survived the first year Median age at death — 58 0.03% survived to age 100
99.3% of infants survived the first year Median age at death — 80 1.5% expected to survive to age 100
to the recognition that microorganisms were the cause of contagious diseases. These observations—along with those of Semmelweiss, Lister, Halsted and many others—led to the concept of aseptic technique and antisepsis in surgical practice. Working from Jenner’s observations, Pasteur established the principle that inoculation with attenuated cultures of an organism could provide protection against rabies infection. The implementation of the public health measures of sewage disposal and sanitary handling of the food and water supplies that arose from this work led to marked improvement in the length and quality of life in industrialized societies. Thus, the fields of microbiology and immunology were born. These scientific fields, invented in the 18th and 19th centuries, were the source of an explosion of discovery during the 20th century and were necessary for many of the advances in our profession. These advances and others led to a significant change in life expectancy during the 20th century (Table I). In 1997, 99.3% of all infants born in the United States survived the first year of life, as compared with only 87.6% in 19004. The median
age at death for persons born in 1900 was 58 and only 0.03% survived to age 100, but for those persons born in 1997, the expected median age at death is calculated to be 80 years and an estimated 1.5% will survive to the age of 100. That represents a 50-fold increase in the number of centenarians. EVOLUTION OF THE SURGEON SCIENTIST IN THE AGE OF BIOLOGY The 20th century was the Era of Physics, and Albert Einstein was appropriately named as the “Person of the Century” by Time magazine. The next century is likely to be the Era of Biology. In an interview with Larry King on Dec 25, 1999, Professor Stephen Hawking, the famous theoretical physicist from Cambridge, was asked what advice he would give to an intelligent young person contemplating a future career.5 Professor Hawking said that he would again choose science and research, but in the area of molecular biology rather than cosmology. He went on to say, “We may find the basic laws that govern the universe, but we will never exhaust the complexity of possible biological systems.”
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Fig 6. Schematic for obtaining a molecular signature from a tumor. The tumor is genotyped, and both the expressed mRNAs and proteins are analyzed from microscopic specimens. This approach is currently under development using animal models. Reproduced with permission from Robert J. Coffey, Jr, MD.
The greatest of the changes that science has brought is the acuity of change; the greatest novelty the extent of novelty. —J. Robert Oppenheimer “The Sciences and Man’s Community” Lecture, 19536
Similar to the scientific foundations laid in the 19th century that led to an understanding of the causes, and in most cases better treatments for infectious diseases, the last 5 decades have brought remarkable advances in our understanding of the molecular basis of many other diseases. In rare cases, diseases may be caused by a single hereditary genetic defect, and these may be successfully treated in the near future by gene replacement therapy. More commonly, multiple factors, both genetic and epigenetic, contribute to the most common lethal diseases, such as diabetes mellitus, cardiovascular disease, and cancer. Now as we enter a new century, it is appropriate to look into a crystal ball to see what the next 100 years has in store for us. One big difference for us as compared to our predecessors from a century ago is the pace of the change that we will experience. Let’s ponder for a moment where we are currently poised in the biological sciences. The human genome will have been completely
Table II. Post-genome era of biology 140,000 genes Function unknown for 2/3 3 × that number of proteins An estimated 1000-4000 useful new protein targets for novel drug therapies
sequenced within the next 3 to 4 years. Of the roughly 140,000 genes in the human genome sequence, for an estimated two thirds, the function is unknown7 (Table II). The post-genomic era of biology will be largely focused on understanding the identities, regulation, and functions of the proteins encoded by these genes. For it is the proteins expressed by the cell that determine the behavior of the cell, thus abnormal function of proteins due to mutation or other defects is the basis of many diseases. There is plenty of work to be done, as there may be as many as 3 times the numbers of different proteins as there are genes in the human genome sequence. This is because single genes often encode more than one protein, and because proteins often undergo post-translational modifications. A new term, proteomics, was coined in 1994 to describe the study of the complete set of proteins that is expressed by a cell. The proteomic approach is likely to provide between 1000 and
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4000 useful protein targets for novel drug therapies for a variety of disorders. The field of proteomics is currently hampered by the need for cumbersome protein separation techniques. It is also hampered by relatively slow antibody production technology and the lack of automated technology that has sped the genome sequencing project. However, we can safely predict that such technology will be developed within the first half of the 21st century. Proteomics and the complementary field transcriptomics (or study of the entire set of transcribed mRNAs in a cell through automated microarray) should enable us to further dissect the causes of complex diseases. As with the infectious diseases, once the fundamental causative mechanisms are understood, we should have a reasonable chance of developing effective treatments. Treatment of diseases such as cancer will be individualized based on the molecular signature of the tumor as well as the molecular signature of the patient’s normal cells. An example of how this approach may develop is depicted in Fig 6, which uses a mouse tumor model for preclinical testing of this technology. Visionary surgical leaders influenced their research-oriented young charges to develop expertise in the field of molecular biology during the 1980s and 1990s. Promising young surgical investigators with basic science interests should now be encouraged to develop expertise in the developing molecular biology fields of proteomics and transcriptomics. Development of dozens of new therapeutic agents will require increased numbers of clinical trials with the parallel need for increased patient accrual rates. University surgeons should be amongst the leaders in the design and implementation of these clinical trials. In the field of cancer, as an example, we provide the most effective single modality of treatment for solid cancers, and the starting point for any adjuvant therapy trial. We are also in a unique position to positively influence the collection and appropriate preservation of patient tissue specimens that are linked to data regarding outcomes for those patients. While I have used the field of cancer treatment as an example, there are many other disease fields in which the surgeon’s leadership position will remain critical to advancement of knowledge. This means that we should provide focused training opportunities to young surgeons interested in clinical research as a part of an academic career. Such training should provide intensive instruction in translational research, biostatistics, trial design, database construction, and data management
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issues. Such training opportunities exist in relatively few places today. Potentially more important than the treatment of disease, we may be able to prevent or delay the onset of many diseases. Let’s again take cancer as an example. Collaborations between surgeons, medical oncologists, pathologists, the pharmaceutical industry, and others have now established that Tamoxifen therapy decreases the incidence of breast cancer by about 50% in women at high risk for developing the disease. A surgeon, Dr William R. Waddell, was the first to make the observation that NSAIDs could inhibit intestinal adenoma formation in patients with familial polyposis, and he published his work in the Journal of Surgical Oncology in 1983.8 Subsequent epidemiological, preclinical, and preliminary clinical trial results suggest that agents that block prostaglandin production may prevent 50% or more of colorectal cancers in susceptible populations. There is tremendous excitement in the scientific and medical communities for ongoing investigations using these and related agents to prevent colorectal cancer, and this concept was first suggested by an observant surgeon who was searching for a better way to treat disease. Will these scientific advances decrease the need for surgeons in the future? That is unlikely, in my opinion. The past teaches us that often when we seem to have solved one problem, several others not previously recognized become apparent. An excellent example of this is found in the field of infectious diseases. Despite remarkable advances, infection remains a significant clinical problem. Vaccination and antibiotics were thought to be the final answers to infection, yet biological diversity and the ability of microorganisms to evolve more rapidly than we can develop new treatments has led to a resurgence in the threats of infectious diseases. Antibiotic resistant strains of bacteria seem to eventually thwart every attempt at eradication. Fungal infections are also becoming resistant to drug therapy. Newly evolved or previously unrecognized viruses continue to be a threat. To quote past-president David Dunn, “All the antibiotics we have today may be useless in the next century, but new antibiotics will come into use.”9 University-based surgeons are appropriately leading the effort to continually fight back against these pathogens. The next era of antimicrobial therapy will depend upon a better understanding of the genetics and biology of these organisms and how they interact with their infected host. Surgical scientists will remain amongst the leaders in this next round of the fight against infection.
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Another area that will be exciting to see evolve is in the field of organ transplantation. The field of developmental biology and stem cell research provides the promise of growing new replacement organs in vitro in the future. These autografts will be transplanted from the petri dish to the patient without the need for immunosuppression. I predict that this will occur well before the dawn of the 22nd century. The surgeon of the future will be operating on older and sicker patients to replace damaged and diseased organs without the limitations in organ donors. I anticipate that some of the research leading to the production of these replacement organs and the early clinical application of this work will be presented at some future meeting of this society. All history teaches us that these questions that we think the pressing ones will be transmuted before they are answered, that they will be replaced by others, and that the very process of discovery will shatter the concepts that we today use to describe our puzzlement. —J. Robert Oppenheimer “Prospects in the Arts and Sciences” Fifty Great Essays (1964)10
MEDICINE MUST EVOLVE TO ADDRESS PATIENT SAFETY CONCERNS A recent development that is likely to precipitate major changes in the field of medicine in the nearterm future is the political and public reaction to the Institute of Medicine report on medical errors as a major cause of death in the United States.11 This report was based upon 2 studies (Table III), one in New York state and another in Colorado and Utah. The New York study was based on a review of randomly selected discharge records of more than 30,000 patients from 51 state hospitals in 1984. The Colorado and Utah study included a random sample of 15,000 discharges from a representative sample of hospitals in the 2 states. Adverse medical events occurred in 3.7% of patients in the New York study and in 2.9% in the Colorado/Utah study. In the New York study, 13.6% of patients who experienced an adverse event died, and 8.8% died in the Colorado/Utah study. The Institute of Medicine’s Committee on Quality of Health Care in America estimated that if these numbers were extrapolated to the number of people hospitalized in the United States, then there were between 44,000 and 98,000 deaths.11 Unfortunately, for those of us who sit in weekly “M and M” conferences, it is not difficult to believe the validity of these figures. To further put these numbers
Table III. Institute of medicine report on medical errors New York study 30,000 patients in 51 hospitals Serious and adverse medical events in 3.7% 13.6% who experienced adverse event died Colorado/Utah study Random sample of 15,000 representative hospital discharges 2.9% adverse events, 8.8% of those died
Table IV. Relative risks Hospital death rate: 3 per 1000 discharges (0.3%) Commercial airline death rate: 1 per 8 million passengers (0.0000125%)
into perspective, consider these comparisons. This number of hospital deaths due to medical error outnumbers the annual death rate for highway accidents (43,458), breast cancer (42,297), or from AIDS (16,516).12 Ninety-eight thousand deaths out of approximately 31 million annual hospital discharges13 equates to a death rate of 3 in 1000 (0.3%), a small percentage, but remember that these are unnecessary iatrogenic deaths (Table IV). In comparison, the risk of death in a commercial airline accident is one in 8 million (or 0.0000125%). If the risk of death from flying in commercial airlines was as great as 0.3%, I daresay that many of us would avoid flying altogether. Clearly the medical error rate is unacceptable. President Clinton and many in Congress have already called for a series of government steps to address the problem, including implementation of many of the recommendations called for by the Institute of Medicine. President Clinton has mandated that private health plans that have contracts with the Federal Employees Health Benefits Program must institute patient safety initiatives. The Senate also plans to hold hearings on these issues, and it is expected that public demand will result in legislation mandating the implementation of the Institute of Medicine’s recommendations.14 The Institute of Medicine recommendations include11: (1) A National Center for Patient Safety to set national safety goals, track progress, fund research on error rates and prevention strategies, and to serve as a clearinghouse of educational information and best practices. (2) Mandatory reporting of errors that cause serious harm or death. While individuals would not be cited in these reports, institutions would be held accountable.
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Table V. How should medicine evolve to reduce medical error? Information technology to reduce medication error Report errors for peer review Required autopsies for hospital deaths Mandatory “M and M” conferences Use “M and M” conferences to accomplish real QA and QI Push outcomes research efforts Sharing of data Development of “best practices” guidelines based on medical evidence
(3) Voluntary reporting of errors that do not have serious consequences (or near-misses). The IOM recommended peer-review protections be extended to cover this level of reporting and that data be collected and analyzed solely to improve safety. (4) Increased attention by standards-setting organizations within medicine, including groups that license and certify physicians and other health care providers. The IOM called for periodic reexaminations to document the practitioners’ competence and knowledge of safety practices. (5) Health insurance agencies should make patient safety a priority in their contractual decisions. How will medicine evolve in response to these recommendations? First, I would like to say that for us in academic medicine, establishment of effective measures to improve patient safety is welcome news. Who would oppose any reasonable measure to improve the outcomes for our patients, as long as these recommendations do not result in the creation of yet another wasteful, ineffective, and self-perpetuating bureaucracy? Second, as leaders in academic medical centers and surgical training programs, many of us already have mechanisms in place to monitor and improve the quality of care within our institutions. We have simply needed the political and legal cover to share, support, enforce, and broadly apply our observations and recommendations. And third, if standards are to be set and physician competence examined, who will do this if not the academic medical centers? Academic institutions have been amongst the leaders in pushing forth the innovations that will help to reduce these errors (Table V). Many of these innovations are designed to correct faulty systems. For example, several academic medical centers have been leaders in the development of computerized order entry systems that have been shown to reduce medication errors.
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Mandatory reporting of serious errors will probably be legislated. Equally important in my opinion will be the reporting of the “near-misses.” In order for this reporting to have maximum effectiveness in error reduction, the elimination of the “culture of blame” that is so pervasive in the United States will be required. The medical community should be provided the legal protection to institute effective peer review and quality assurance measures to minimize these deadly errors. Autopsies should be required on all patients who die in the hospital, and this service should be reimbursed by third-party payers. Autopsy results will be a key to having meaningful Morbidity and Mortality conferences. Too often Morbidity and Mortality conferences are cursorily performed and may not be performed at all in many hospitals outside of the academic setting. Hospital deaths on all clinical services should be reviewed in Morbidity and Mortality conferences with the goal of identifying patient safety problems and improving the quality of care. Academic surgeons should lead the way in these efforts. Over the past decade, data have emerged to show that patients undergoing complex surgical procedures have better outcomes when their operations are done in centers or by surgeons performing a high volume of those particular cases. This has been shown to be true for coronary artery bypass and pancreaticoduodenectomy amongst others. Mandatory reporting and sharing of outcomes data along with the implementation of evidence-based practice guidelines will reinforce these conclusions. In contradiction to what we have been told by managed care organizations, I believe that patients and third-party payers will begin to demand the quality of tertiary and quaternary care that our university hospitals are uniquely positioned to provide. In addition, this push for improved quality and safety will open new avenues for academic research, with new funding to support these efforts. We are the first species to have taken our evolution into our own hands. —Carl Sagan Broca’s Brain: Reflections on the Romance of Science [1979]15
Our role as academic surgeons is to evolve our training programs in order to meet the challenges that will be presented in the future. The surgeon of the future will have an even greater need to understand the biology of the diseases they treat and to know which treatments are most likely to work in a given patient based on the best available medical
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Fig 7. The number of applications for membership to the SUS from 1996 to the present.
evidence. We will need to have a clear understanding of how our modality of treatment complements nonsurgical approaches. EVOLUTION OF THE SUS I have given you several examples of my views on the evolution of medicine and within it the field of academic surgery. Now I would like to spend the remaining few minutes discussing the evolution of the Society of University Surgeons. In his 1998 presidential address to this society, Keith Lillemoe16 noted disturbing trends within the organization, and he proposed a number of strategic changes to reverse those trends. Dr Lillemoe noted that meeting attendance had been steadily decreasing and that the Saturday morning portion of the program was sparsely attended and very few members stayed for the Saturday afternoon residents’ meeting. He also pointed out the decreasing trend in applications for membership in the Society. After noting these trends, Dr Lillemoe surveyed the membership, 20 past presidents, and 40 current surgical chairs to obtain their perceptions of the SUS and their ideas regarding improvement. Amongst the changes that were suggested to improve the annual meeting were: (1) more clinical papers; (2) parallel sessions; (3) a broadened program to include both clinical and basic research topics; (4) increase the number of members; (5) reassess the membership selection process. What has been our response to these suggestions from our membership? During the past 2 years, the Executive Council has discussed and enacted several important changes (Table VI). Those of you who have attended the meetings over the past several years will have already noted signif-
Table VI. How is the SUS evolving? Incorporation of the residents’ program into the main meeting Clinical outcomes papers Parallel sessions Topic forums Increased number of papers Professional management
icant changes in the structure of the meeting. The beginnings of these changes were initiated by President Cioffi’s administration and were introduced at the meeting in New Orleans last year; with the incorporation of the residents’ program into the Thursday afternoon segment of the main meeting. We have had a tremendous amount of positive feedback regarding this change. Another change that began last year was the solicitation of Clinical Outcomes papers and a special session devoted to clinical outcomes. Parallel sessions were begun last year, and we have more of them this year. In making these changes, we have increased the number of papers presented during the meeting from 45 in 1997 to 53 this year (not including the residents’ papers). At the same time, we have included both a basic science forum and a clinical topic forum that will significantly enhance the program. We have actively contacted most of the surgical department chairs in America to solicit new member nominees. As a result, there has been an increase in new member applications. This year, we had 84 applicants for 61 new membership positions, which reverses the decreasing trend that we had observed over the previous 4 years (Fig 7). There appears to be renewed interest in hosting the annual meeting. This year, more institutions
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have expressed interest in hosting the future annual meetings than I have observed in my time on the Executive Council. This year, we had 28 university surgery programs submit proposals to host the 2004 SUS meeting. With the assistance of the management team at Crow-Segal, the job of hosting future meetings will also be greatly simplified. We have also begun the process of bylaws changes that, if passed tomorrow during the business session, will increase the age of active membership to 50. The number of active members 45 and younger will remain at 250, but the total active membership will nearly double over the next 5 years due to the increasing age of membership. This change will enable academic surgeons who may have received extended training ample time to achieve membership and will enable them to remain active members, including the possibility of holding office for at least 5 years after they join. I fully expect that this evolution of the Society of University Surgeons will reinvigorate this organization. The SUS is and will remain the most prestigious surgical society to which young academic surgeons may aspire to membership. We must assert our leadership position in the inevitable evolution of the field of surgery and in the complementary changes within our educational and training programs that will be necessary in order for us to adapt to future societal needs. I foresee the future of the SUS as a bright one, and we should embrace the opportunities presented with the coming changes. I will leave you this evening with this quote from Robert Oppenheimer that I believe has ageless relevance for the university surgeon: It is proper to the role of the scientist that he not merely find new truth and communicate it to his fellows, but that he teach, that he try to bring the most honest and intelligible account of new knowledge to all who will try to learn. “Prospects in the Arts and Sciences” (1964)10
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Thank you for your kind attention and for the honor of allowing me to serve this Society.
REFERENCES 1. Schwartz SI. Reflections. Ann Surg 1994;220:227-36. 2. Santayana G. Little essays drawn from the writings of George Santayana. Freeport (NY) Books for Libraries Press; 1967. 3. Lyons AS, Petrucelli RJ. Medicine: An illustrated history. 2nd ed. New York: Abradale Press; 1987. 4. Anderson RN. United States Life Tables, 1997. Natl Vital Stat Rep 1999;47:1-6. 5. King L, Hawking S. Stephen Hawking discusses quantum physics and ALS, Vol 1995: Cable News Network, Larry King Live Weekend, 1999. 6. Oppenheimer JR. J Robert Oppenheimer; [a register of his papers in the Library of Congress]. Registers of papers in the Manuscript Division of the Library of Congress, [no 43], 1974. 7. Abbott A. A post-genomic challenge: learning to read patterns of protein synthesis. Nature 1999;402:715-8. 8. Waddell WR, Loughry RW. Sulindac for polyposis of the colon. J. Surg Oncol 1983;24:83-7. 9. Mitka M. Preventing surgical infection is more important than ever. JAMA 2000;283:44-5. 10. Oppenheimer JR. Prospects in the arts and sciences. In Huberman E, editor. Fifty great essays. New York: Bantam Books; 1964. 11. Kohn L, Corrigan J, Donaldson M. To err is human. In: Committee on quality of health care in America IOM, editors. Washington, DC: National Academy Press; 1999. p. 300. 12. Kennedy R. Public lives; the health profession is his worst patient. The New York Times 1999. 13. Graves EJ, Owings MF. 1996 Summary: national hospital discharge survey. National Center for Health Statistics, 1998. 14. Prager LO. Report unleashes furious interest in medical errors. American Medical News, Vol 42. American Medical Association, 1999. pp. 1, 37-38. 15. Sagan C. Broca’s brain: reflections on the romance of science. New York: Random House; 1979. 16. Lillemoe KD. Presidential address: SUS-SOS? Surgery 1998;124:121-8.
Number 2
SURGERY AUGUST
2000
Society of University Surgeons Presidential address: Evolution R. Daniel Beauchamp, MD, Nashville, Tenn
From the Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tenn
IT HAS BEEN MY GREAT HONOR and privilege to serve as the president of the Society of University Surgeons for the past year and to have served on the Executive Council for a total of 5 years. I wish to thank you for the opportunity that you have given me to serve this society and to address you on this the 61st annual SUS meeting. In keeping with tradition, I sought inspiration for this address by reviewing countless prior published presidential addresses. I took some measure of comfort in this task from the realization that many have tread similar ground in the past and have survived to tell about it. My anticipation of this event was similar to that expressed by Seymour I. Schwartz1 in his 1994 Presidential Address to the American Surgical Association. He said, “The past year has also been characterized by recurrent anxiety related to the preparation of an address that is inevitably exposed to comparison and criticism but, fortunately, is rarely remembered by the audience.” Perhaps the best advice I received regarding the preparation of this address was from my mother. She advised me to keep it brief. She said, “You know how it feels to sit through one of those longwinded speeches.” Presented at the 61st Annual Meeting of the Society of University Surgeons, Toronto, Ontario, Canada, February 1012, 2000. Reprint requests: Daniel Beauchamp, MD, Department of Surgery, Vanderbilt University School of Medicine, 21st Ave S, MCN D5230, Nashville, TN 37232-2729. Surgery 2000;128:123-32 Copyright © 2000 by Mosby, Inc. 0039-6060/2000/$12.00 + 0 doi:10.1067/msy.2000.108057
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Before I proceed with my address, I first want to publicly recognize and thank several important people in my life. First and foremost I want to thank my wife, Shannon, and our daughter, Bryn, for their love and support. I also wish to thank them for their tolerance of the selfish pursuits inherent in this career. They have taught me the most important treasures of this life. I also wish to recognize and thank several people who have been kind enough to serve as mentors to me over the past 20 years. Courtney M. Townsend, Jr and James C. Thompson have both served as my role models as surgeon scientists. Jim Thompson (Fig 1) was the Chairman of Surgery during my residency and was my first boss as a junior faculty member at the University of Texas Medical Branch in Galveston. Jim is the Ashbel Smith Distinguished Professor at UTMB and is currently the President of the American College of Surgeons. Courtney Townsend (Fig 2) has been my mentor since my first clinical clerkship in surgery as a third-year medical student, and he remains a valued scientific and surgical mentor. Courtney is currently Chairman of Surgery at UTMB. I was fortunate enough to have been educated and to have received my surgical and initial scientific training working with these two men who are truly University Surgeons in every respect. With these two as role models, it never occurred to me to question whether one could simultaneously be an excellent clinical surgeon, a successful scientific investigator, a dedicated educator, and an effective administrator. I now realize the degree of difficulty involved in balancing these very different SURGERY 123
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Fig 1. James C. Thompson, MD, former chairman of the Department of Surgery at the University of Texas Medical Branch.
aspects of a career as a surgical leader. I continue to seek their counsel on a regular basis. I also wish to thank another of my mentors, Harold Moses (Fig 3), who is currently the Director of the Vanderbilt-Ingram Cancer Center. Hal took a chance in inviting a young surgeon to be a postdoctoral fellow in his cell biology laboratory at Vanderbilt in 1987. Hal was also instrumental in my returning to Vanderbilt in 1994 to join in his efforts to build scientific and clinical programs in the new cancer center. I continue to learn a great deal about both science and organizational management by working with Hal in the Vanderbilt-Ingram Cancer Center. I wish to recognize and thank James A. O’Neill, Jr (Fig 4), the Chairman of Surgery at Vanderbilt University Medical Center. Jim became Chairman of Surgery at about the same time that I moved back to Nashville at the end of 1994. I could not have asked for a more fair and supportive chairman. Both Jim O’Neill and my previous chairman Jim Thompson have been outstanding in their attention to detail in the development of young faculty members. Jim O’Neill is my role model for a leadership style characterized by equanimity, and I am fortunate to work under his guidance. Finally, I wish to thank all of my colleagues, the residents, fellows, students, and patients at the Vanderbilt University Medical Center for making it fun to come to work every day. This talk is entitled “Evolution.” The first definition of evolution in Webster’s dictionary is “a gradual process in which something changes into a sig-
Fig 2. Courtney M. Townsend, MD, current chairman of the Department of Surgery at the University of Texas Medical Branch.
nificantly different, especially more complex or more sophisticated, form.” This applies to biological systems, to societies, and to organizations. I want to briefly discuss the evolution that we are experiencing in the broad field of medicine and how it relates to us in the specific arena of academic surgery. Like Darwin’s finches, we must evolve in order to adapt to our world lest we face extinction. It is vital that the rising leaders in academic surgery, largely comprised of members of the Society of University Surgeons, are prepared to evolve so that we may adequately adapt to the needs of our patients and to the educational and training requirements of the next generations of surgeons. We also must adapt in order to continue to make scientific contributions aimed at improving our understanding and treatment of the diseases that we confront. The tide of evolution carries everything before it, thoughts no less than bodies, and persons no less than nations. —George Santayana Little Essays (1920)2
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Fig 4. James A. O’Neill, Jr, MD, chairman of the Department of Surgery at the Vanderbilt University School of Medicine. Fig 3. Harold L. Moses, MD, director of the VanderbiltIngram Cancer Center at the Vanderbilt University School of Medicine.
We need no better indication of the changes that will occur in our profession over the next century than to briefly ponder some of the remarkable changes that have occurred over the past century. At the beginning of the 20th century, one would have had to travel several days, if not weeks, to attend this meeting. Travel to work was mostly by foot, horseback, or horse-drawn carriage; and house calls by a horse-mounted physician who concocted his own medications carried in a saddlebag were not uncommon. Yet the automobile had already been invented in Germany, and the assembly lines engineered by Henry Ford were soon to make it affordable for the masses. The Wright brothers were preparing for their first historic flight that would lead in only a few decades to commercial airline transportation that has largely supplanted rail, buses, and ships for long-distance transportation. The application of electric energy in every facet of life would dramatically change the ways we worked and lived and would extend the potential period of human productivity from
around 12 hours to 24 hours per day. During the 20th century, the telephone, radio, television, and finally the computer would revolutionize our method of communication. Current information technology, the Internet, and affordable air travel have continued to revolutionize communication and have made the world a much smaller place in which to live. At the turn of the 20th century, the field of medicine was also poised to make numerous rapid advances.3 A century before, Edward Jenner had already established the concept of infectious disease prevention in his famous 1798 paper describing a successful technique of inoculating humans with fluid from the sores of vaccinia, or cowpox, to prevent infection with smallpox, the single most deadly infectious killer of that period. Jenner’s remarkable observations were not immediately accepted by the general public as one may see in a cartoon from that era depicting potential complications after inoculation with the cowpox vaccine (Fig 5). Pioneering work by many other investigators including Louis Pasteur, Robert Koch, and many others working in the 18th and 19th centuries led
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Fig 5. James Gillray’s The Cow-Pock-or-the wonderful effects of the new inoculation! (1802). (Courtesy of the National Library of Medicine, Bethesda.)
Table I. Changes in life expectancy 1900
1997
87.6% of infants survived the first year Median age at death — 58 0.03% survived to age 100
99.3% of infants survived the first year Median age at death — 80 1.5% expected to survive to age 100
to the recognition that microorganisms were the cause of contagious diseases. These observations—along with those of Semmelweiss, Lister, Halsted and many others—led to the concept of aseptic technique and antisepsis in surgical practice. Working from Jenner’s observations, Pasteur established the principle that inoculation with attenuated cultures of an organism could provide protection against rabies infection. The implementation of the public health measures of sewage disposal and sanitary handling of the food and water supplies that arose from this work led to marked improvement in the length and quality of life in industrialized societies. Thus, the fields of microbiology and immunology were born. These scientific fields, invented in the 18th and 19th centuries, were the source of an explosion of discovery during the 20th century and were necessary for many of the advances in our profession. These advances and others led to a significant change in life expectancy during the 20th century (Table I). In 1997, 99.3% of all infants born in the United States survived the first year of life, as compared with only 87.6% in 19004. The median
age at death for persons born in 1900 was 58 and only 0.03% survived to age 100, but for those persons born in 1997, the expected median age at death is calculated to be 80 years and an estimated 1.5% will survive to the age of 100. That represents a 50-fold increase in the number of centenarians. EVOLUTION OF THE SURGEON SCIENTIST IN THE AGE OF BIOLOGY The 20th century was the Era of Physics, and Albert Einstein was appropriately named as the “Person of the Century” by Time magazine. The next century is likely to be the Era of Biology. In an interview with Larry King on Dec 25, 1999, Professor Stephen Hawking, the famous theoretical physicist from Cambridge, was asked what advice he would give to an intelligent young person contemplating a future career.5 Professor Hawking said that he would again choose science and research, but in the area of molecular biology rather than cosmology. He went on to say, “We may find the basic laws that govern the universe, but we will never exhaust the complexity of possible biological systems.”
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Fig 6. Schematic for obtaining a molecular signature from a tumor. The tumor is genotyped, and both the expressed mRNAs and proteins are analyzed from microscopic specimens. This approach is currently under development using animal models. Reproduced with permission from Robert J. Coffey, Jr, MD.
The greatest of the changes that science has brought is the acuity of change; the greatest novelty the extent of novelty. —J. Robert Oppenheimer “The Sciences and Man’s Community” Lecture, 19536
Similar to the scientific foundations laid in the 19th century that led to an understanding of the causes, and in most cases better treatments for infectious diseases, the last 5 decades have brought remarkable advances in our understanding of the molecular basis of many other diseases. In rare cases, diseases may be caused by a single hereditary genetic defect, and these may be successfully treated in the near future by gene replacement therapy. More commonly, multiple factors, both genetic and epigenetic, contribute to the most common lethal diseases, such as diabetes mellitus, cardiovascular disease, and cancer. Now as we enter a new century, it is appropriate to look into a crystal ball to see what the next 100 years has in store for us. One big difference for us as compared to our predecessors from a century ago is the pace of the change that we will experience. Let’s ponder for a moment where we are currently poised in the biological sciences. The human genome will have been completely
Table II. Post-genome era of biology 140,000 genes Function unknown for 2/3 3 × that number of proteins An estimated 1000-4000 useful new protein targets for novel drug therapies
sequenced within the next 3 to 4 years. Of the roughly 140,000 genes in the human genome sequence, for an estimated two thirds, the function is unknown7 (Table II). The post-genomic era of biology will be largely focused on understanding the identities, regulation, and functions of the proteins encoded by these genes. For it is the proteins expressed by the cell that determine the behavior of the cell, thus abnormal function of proteins due to mutation or other defects is the basis of many diseases. There is plenty of work to be done, as there may be as many as 3 times the numbers of different proteins as there are genes in the human genome sequence. This is because single genes often encode more than one protein, and because proteins often undergo post-translational modifications. A new term, proteomics, was coined in 1994 to describe the study of the complete set of proteins that is expressed by a cell. The proteomic approach is likely to provide between 1000 and
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4000 useful protein targets for novel drug therapies for a variety of disorders. The field of proteomics is currently hampered by the need for cumbersome protein separation techniques. It is also hampered by relatively slow antibody production technology and the lack of automated technology that has sped the genome sequencing project. However, we can safely predict that such technology will be developed within the first half of the 21st century. Proteomics and the complementary field transcriptomics (or study of the entire set of transcribed mRNAs in a cell through automated microarray) should enable us to further dissect the causes of complex diseases. As with the infectious diseases, once the fundamental causative mechanisms are understood, we should have a reasonable chance of developing effective treatments. Treatment of diseases such as cancer will be individualized based on the molecular signature of the tumor as well as the molecular signature of the patient’s normal cells. An example of how this approach may develop is depicted in Fig 6, which uses a mouse tumor model for preclinical testing of this technology. Visionary surgical leaders influenced their research-oriented young charges to develop expertise in the field of molecular biology during the 1980s and 1990s. Promising young surgical investigators with basic science interests should now be encouraged to develop expertise in the developing molecular biology fields of proteomics and transcriptomics. Development of dozens of new therapeutic agents will require increased numbers of clinical trials with the parallel need for increased patient accrual rates. University surgeons should be amongst the leaders in the design and implementation of these clinical trials. In the field of cancer, as an example, we provide the most effective single modality of treatment for solid cancers, and the starting point for any adjuvant therapy trial. We are also in a unique position to positively influence the collection and appropriate preservation of patient tissue specimens that are linked to data regarding outcomes for those patients. While I have used the field of cancer treatment as an example, there are many other disease fields in which the surgeon’s leadership position will remain critical to advancement of knowledge. This means that we should provide focused training opportunities to young surgeons interested in clinical research as a part of an academic career. Such training should provide intensive instruction in translational research, biostatistics, trial design, database construction, and data management
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issues. Such training opportunities exist in relatively few places today. Potentially more important than the treatment of disease, we may be able to prevent or delay the onset of many diseases. Let’s again take cancer as an example. Collaborations between surgeons, medical oncologists, pathologists, the pharmaceutical industry, and others have now established that Tamoxifen therapy decreases the incidence of breast cancer by about 50% in women at high risk for developing the disease. A surgeon, Dr William R. Waddell, was the first to make the observation that NSAIDs could inhibit intestinal adenoma formation in patients with familial polyposis, and he published his work in the Journal of Surgical Oncology in 1983.8 Subsequent epidemiological, preclinical, and preliminary clinical trial results suggest that agents that block prostaglandin production may prevent 50% or more of colorectal cancers in susceptible populations. There is tremendous excitement in the scientific and medical communities for ongoing investigations using these and related agents to prevent colorectal cancer, and this concept was first suggested by an observant surgeon who was searching for a better way to treat disease. Will these scientific advances decrease the need for surgeons in the future? That is unlikely, in my opinion. The past teaches us that often when we seem to have solved one problem, several others not previously recognized become apparent. An excellent example of this is found in the field of infectious diseases. Despite remarkable advances, infection remains a significant clinical problem. Vaccination and antibiotics were thought to be the final answers to infection, yet biological diversity and the ability of microorganisms to evolve more rapidly than we can develop new treatments has led to a resurgence in the threats of infectious diseases. Antibiotic resistant strains of bacteria seem to eventually thwart every attempt at eradication. Fungal infections are also becoming resistant to drug therapy. Newly evolved or previously unrecognized viruses continue to be a threat. To quote past-president David Dunn, “All the antibiotics we have today may be useless in the next century, but new antibiotics will come into use.”9 University-based surgeons are appropriately leading the effort to continually fight back against these pathogens. The next era of antimicrobial therapy will depend upon a better understanding of the genetics and biology of these organisms and how they interact with their infected host. Surgical scientists will remain amongst the leaders in this next round of the fight against infection.
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Another area that will be exciting to see evolve is in the field of organ transplantation. The field of developmental biology and stem cell research provides the promise of growing new replacement organs in vitro in the future. These autografts will be transplanted from the petri dish to the patient without the need for immunosuppression. I predict that this will occur well before the dawn of the 22nd century. The surgeon of the future will be operating on older and sicker patients to replace damaged and diseased organs without the limitations in organ donors. I anticipate that some of the research leading to the production of these replacement organs and the early clinical application of this work will be presented at some future meeting of this society. All history teaches us that these questions that we think the pressing ones will be transmuted before they are answered, that they will be replaced by others, and that the very process of discovery will shatter the concepts that we today use to describe our puzzlement. —J. Robert Oppenheimer “Prospects in the Arts and Sciences” Fifty Great Essays (1964)10
MEDICINE MUST EVOLVE TO ADDRESS PATIENT SAFETY CONCERNS A recent development that is likely to precipitate major changes in the field of medicine in the nearterm future is the political and public reaction to the Institute of Medicine report on medical errors as a major cause of death in the United States.11 This report was based upon 2 studies (Table III), one in New York state and another in Colorado and Utah. The New York study was based on a review of randomly selected discharge records of more than 30,000 patients from 51 state hospitals in 1984. The Colorado and Utah study included a random sample of 15,000 discharges from a representative sample of hospitals in the 2 states. Adverse medical events occurred in 3.7% of patients in the New York study and in 2.9% in the Colorado/Utah study. In the New York study, 13.6% of patients who experienced an adverse event died, and 8.8% died in the Colorado/Utah study. The Institute of Medicine’s Committee on Quality of Health Care in America estimated that if these numbers were extrapolated to the number of people hospitalized in the United States, then there were between 44,000 and 98,000 deaths.11 Unfortunately, for those of us who sit in weekly “M and M” conferences, it is not difficult to believe the validity of these figures. To further put these numbers
Table III. Institute of medicine report on medical errors New York study 30,000 patients in 51 hospitals Serious and adverse medical events in 3.7% 13.6% who experienced adverse event died Colorado/Utah study Random sample of 15,000 representative hospital discharges 2.9% adverse events, 8.8% of those died
Table IV. Relative risks Hospital death rate: 3 per 1000 discharges (0.3%) Commercial airline death rate: 1 per 8 million passengers (0.0000125%)
into perspective, consider these comparisons. This number of hospital deaths due to medical error outnumbers the annual death rate for highway accidents (43,458), breast cancer (42,297), or from AIDS (16,516).12 Ninety-eight thousand deaths out of approximately 31 million annual hospital discharges13 equates to a death rate of 3 in 1000 (0.3%), a small percentage, but remember that these are unnecessary iatrogenic deaths (Table IV). In comparison, the risk of death in a commercial airline accident is one in 8 million (or 0.0000125%). If the risk of death from flying in commercial airlines was as great as 0.3%, I daresay that many of us would avoid flying altogether. Clearly the medical error rate is unacceptable. President Clinton and many in Congress have already called for a series of government steps to address the problem, including implementation of many of the recommendations called for by the Institute of Medicine. President Clinton has mandated that private health plans that have contracts with the Federal Employees Health Benefits Program must institute patient safety initiatives. The Senate also plans to hold hearings on these issues, and it is expected that public demand will result in legislation mandating the implementation of the Institute of Medicine’s recommendations.14 The Institute of Medicine recommendations include11: (1) A National Center for Patient Safety to set national safety goals, track progress, fund research on error rates and prevention strategies, and to serve as a clearinghouse of educational information and best practices. (2) Mandatory reporting of errors that cause serious harm or death. While individuals would not be cited in these reports, institutions would be held accountable.
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Table V. How should medicine evolve to reduce medical error? Information technology to reduce medication error Report errors for peer review Required autopsies for hospital deaths Mandatory “M and M” conferences Use “M and M” conferences to accomplish real QA and QI Push outcomes research efforts Sharing of data Development of “best practices” guidelines based on medical evidence
(3) Voluntary reporting of errors that do not have serious consequences (or near-misses). The IOM recommended peer-review protections be extended to cover this level of reporting and that data be collected and analyzed solely to improve safety. (4) Increased attention by standards-setting organizations within medicine, including groups that license and certify physicians and other health care providers. The IOM called for periodic reexaminations to document the practitioners’ competence and knowledge of safety practices. (5) Health insurance agencies should make patient safety a priority in their contractual decisions. How will medicine evolve in response to these recommendations? First, I would like to say that for us in academic medicine, establishment of effective measures to improve patient safety is welcome news. Who would oppose any reasonable measure to improve the outcomes for our patients, as long as these recommendations do not result in the creation of yet another wasteful, ineffective, and self-perpetuating bureaucracy? Second, as leaders in academic medical centers and surgical training programs, many of us already have mechanisms in place to monitor and improve the quality of care within our institutions. We have simply needed the political and legal cover to share, support, enforce, and broadly apply our observations and recommendations. And third, if standards are to be set and physician competence examined, who will do this if not the academic medical centers? Academic institutions have been amongst the leaders in pushing forth the innovations that will help to reduce these errors (Table V). Many of these innovations are designed to correct faulty systems. For example, several academic medical centers have been leaders in the development of computerized order entry systems that have been shown to reduce medication errors.
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Mandatory reporting of serious errors will probably be legislated. Equally important in my opinion will be the reporting of the “near-misses.” In order for this reporting to have maximum effectiveness in error reduction, the elimination of the “culture of blame” that is so pervasive in the United States will be required. The medical community should be provided the legal protection to institute effective peer review and quality assurance measures to minimize these deadly errors. Autopsies should be required on all patients who die in the hospital, and this service should be reimbursed by third-party payers. Autopsy results will be a key to having meaningful Morbidity and Mortality conferences. Too often Morbidity and Mortality conferences are cursorily performed and may not be performed at all in many hospitals outside of the academic setting. Hospital deaths on all clinical services should be reviewed in Morbidity and Mortality conferences with the goal of identifying patient safety problems and improving the quality of care. Academic surgeons should lead the way in these efforts. Over the past decade, data have emerged to show that patients undergoing complex surgical procedures have better outcomes when their operations are done in centers or by surgeons performing a high volume of those particular cases. This has been shown to be true for coronary artery bypass and pancreaticoduodenectomy amongst others. Mandatory reporting and sharing of outcomes data along with the implementation of evidence-based practice guidelines will reinforce these conclusions. In contradiction to what we have been told by managed care organizations, I believe that patients and third-party payers will begin to demand the quality of tertiary and quaternary care that our university hospitals are uniquely positioned to provide. In addition, this push for improved quality and safety will open new avenues for academic research, with new funding to support these efforts. We are the first species to have taken our evolution into our own hands. —Carl Sagan Broca’s Brain: Reflections on the Romance of Science [1979]15
Our role as academic surgeons is to evolve our training programs in order to meet the challenges that will be presented in the future. The surgeon of the future will have an even greater need to understand the biology of the diseases they treat and to know which treatments are most likely to work in a given patient based on the best available medical
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Fig 7. The number of applications for membership to the SUS from 1996 to the present.
evidence. We will need to have a clear understanding of how our modality of treatment complements nonsurgical approaches. EVOLUTION OF THE SUS I have given you several examples of my views on the evolution of medicine and within it the field of academic surgery. Now I would like to spend the remaining few minutes discussing the evolution of the Society of University Surgeons. In his 1998 presidential address to this society, Keith Lillemoe16 noted disturbing trends within the organization, and he proposed a number of strategic changes to reverse those trends. Dr Lillemoe noted that meeting attendance had been steadily decreasing and that the Saturday morning portion of the program was sparsely attended and very few members stayed for the Saturday afternoon residents’ meeting. He also pointed out the decreasing trend in applications for membership in the Society. After noting these trends, Dr Lillemoe surveyed the membership, 20 past presidents, and 40 current surgical chairs to obtain their perceptions of the SUS and their ideas regarding improvement. Amongst the changes that were suggested to improve the annual meeting were: (1) more clinical papers; (2) parallel sessions; (3) a broadened program to include both clinical and basic research topics; (4) increase the number of members; (5) reassess the membership selection process. What has been our response to these suggestions from our membership? During the past 2 years, the Executive Council has discussed and enacted several important changes (Table VI). Those of you who have attended the meetings over the past several years will have already noted signif-
Table VI. How is the SUS evolving? Incorporation of the residents’ program into the main meeting Clinical outcomes papers Parallel sessions Topic forums Increased number of papers Professional management
icant changes in the structure of the meeting. The beginnings of these changes were initiated by President Cioffi’s administration and were introduced at the meeting in New Orleans last year; with the incorporation of the residents’ program into the Thursday afternoon segment of the main meeting. We have had a tremendous amount of positive feedback regarding this change. Another change that began last year was the solicitation of Clinical Outcomes papers and a special session devoted to clinical outcomes. Parallel sessions were begun last year, and we have more of them this year. In making these changes, we have increased the number of papers presented during the meeting from 45 in 1997 to 53 this year (not including the residents’ papers). At the same time, we have included both a basic science forum and a clinical topic forum that will significantly enhance the program. We have actively contacted most of the surgical department chairs in America to solicit new member nominees. As a result, there has been an increase in new member applications. This year, we had 84 applicants for 61 new membership positions, which reverses the decreasing trend that we had observed over the previous 4 years (Fig 7). There appears to be renewed interest in hosting the annual meeting. This year, more institutions
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have expressed interest in hosting the future annual meetings than I have observed in my time on the Executive Council. This year, we had 28 university surgery programs submit proposals to host the 2004 SUS meeting. With the assistance of the management team at Crow-Segal, the job of hosting future meetings will also be greatly simplified. We have also begun the process of bylaws changes that, if passed tomorrow during the business session, will increase the age of active membership to 50. The number of active members 45 and younger will remain at 250, but the total active membership will nearly double over the next 5 years due to the increasing age of membership. This change will enable academic surgeons who may have received extended training ample time to achieve membership and will enable them to remain active members, including the possibility of holding office for at least 5 years after they join. I fully expect that this evolution of the Society of University Surgeons will reinvigorate this organization. The SUS is and will remain the most prestigious surgical society to which young academic surgeons may aspire to membership. We must assert our leadership position in the inevitable evolution of the field of surgery and in the complementary changes within our educational and training programs that will be necessary in order for us to adapt to future societal needs. I foresee the future of the SUS as a bright one, and we should embrace the opportunities presented with the coming changes. I will leave you this evening with this quote from Robert Oppenheimer that I believe has ageless relevance for the university surgeon: It is proper to the role of the scientist that he not merely find new truth and communicate it to his fellows, but that he teach, that he try to bring the most honest and intelligible account of new knowledge to all who will try to learn. “Prospects in the Arts and Sciences” (1964)10
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Thank you for your kind attention and for the honor of allowing me to serve this Society.
REFERENCES 1. Schwartz SI. Reflections. Ann Surg 1994;220:227-36. 2. Santayana G. Little essays drawn from the writings of George Santayana. Freeport (NY) Books for Libraries Press; 1967. 3. Lyons AS, Petrucelli RJ. Medicine: An illustrated history. 2nd ed. New York: Abradale Press; 1987. 4. Anderson RN. United States Life Tables, 1997. Natl Vital Stat Rep 1999;47:1-6. 5. King L, Hawking S. Stephen Hawking discusses quantum physics and ALS, Vol 1995: Cable News Network, Larry King Live Weekend, 1999. 6. Oppenheimer JR. J Robert Oppenheimer; [a register of his papers in the Library of Congress]. Registers of papers in the Manuscript Division of the Library of Congress, [no 43], 1974. 7. Abbott A. A post-genomic challenge: learning to read patterns of protein synthesis. Nature 1999;402:715-8. 8. Waddell WR, Loughry RW. Sulindac for polyposis of the colon. J. Surg Oncol 1983;24:83-7. 9. Mitka M. Preventing surgical infection is more important than ever. JAMA 2000;283:44-5. 10. Oppenheimer JR. Prospects in the arts and sciences. In Huberman E, editor. Fifty great essays. New York: Bantam Books; 1964. 11. Kohn L, Corrigan J, Donaldson M. To err is human. In: Committee on quality of health care in America IOM, editors. Washington, DC: National Academy Press; 1999. p. 300. 12. Kennedy R. Public lives; the health profession is his worst patient. The New York Times 1999. 13. Graves EJ, Owings MF. 1996 Summary: national hospital discharge survey. National Center for Health Statistics, 1998. 14. Prager LO. Report unleashes furious interest in medical errors. American Medical News, Vol 42. American Medical Association, 1999. pp. 1, 37-38. 15. Sagan C. Broca’s brain: reflections on the romance of science. New York: Random House; 1979. 16. Lillemoe KD. Presidential address: SUS-SOS? Surgery 1998;124:121-8.