The role of research in the surgery of tomorrow

PRESIDENTIAL ADDRESS

The Role of Research in the Surgery of Tomorrow

James C. Thompson, MD, Galveston, Texas

I have been greatly honored to serve as the 23rd president of this splendid young organization. We now have almost 1,000 members, which makes us a candidate for the big league of professional organizations. The future is bright for the Society, and will be limited chiefly by our imaginations. On occasions such as this, the author should choose a topic about which he has deep personal involvement. I have spent a lifetime in research, and I have seen the benefits that our Society has received from it. I have a simple syllogism that states that the medicine of today is successful largely because of the research of yesterday, and if we fail today to vigorously pursue research, the medicine of tomorrow will be the medicine of today. That is the simple guiding theme, the message that I have. Benefits of medical progress: Some of the benefits of medical progress to society in general are easily perceived. A review of mortality rates for three standard injuries in our last six wars (Table I) gives a dramatic indication of improvement in surgical care [ 1, personal communication: C. Ellsworth, U.S. Army Center of Military History, Washington, DC]. There has been a sixfold decrease in mortality from head injuries, a 12-fold decrease from chest wounds, and from World War I to Viet Nam, there was a lo-fold decrease in mortality from colon wounds. When my parents were born just after the turn of the century, life expectancy in this country was less than 50 years (Figure 1) 121.My grandchildren have a life expectancy of nearly 80 years (at least my granddaughter does). Much of this increased expectancy is, of course, brought about by better plumbing and other public health measures, but progress in medicine should and does get a lot of the credit. From the Dqwtmant of Swgery. University of Texas kdicd Branch, CMv&on. Texas. Raqwsts fa reprints should be arktressed to Jarnf~s C. Thompson. MD. bpdtnMt of Surm. University of Texas Medical Branch, Qatveston, Texas 77550. Presented at the 24th Annual Meeting of the Society for Surgery of tie Alinwtary Tract. Washlngton. CC. May 24-25. 1993.

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Surgical research has made salient contributions to progress. Many of the most important of these are listed in Table II. Thousands of lives and millions of dollars have been saved as a result of these and similar innovations, indeed, much of the present system of secondary and tertiary health care in North America, Western Europe, and Japan have been derived from them. Funding of biomedical research: How did all of this improvement in medical care come about? Some of it naturally followed the great improvement in medical school education and, as Lewis Thomas has pointed out in his new book, The Youngest Science (31, much of it is due to brilliant advances in pharmacology and to the startling adaptations of technology to medicine. Older members of our organization have witnessed with rapt attention the rapid evolution of one of the great forces for change, that is, the emergence of the National Institutes of Health (NIH) as a major stimulant and source of support for medical research. The development of the NIH was nurtured and prodded by the unusual and highly effective triumvirate of Representative John Fogarty, Senator Lister Hill, and Dr. James Shannon, the long-term director of the NIH. These geniuses were able to convince Congress, various Presidents, and the United States public that it was proper and right for the federal government to nurture the development of biomedical research, and for many years, medical research in this country was nurtured in an extraordinary manner. Biomedical research in the United States is supported by the federal government, industry, and private philanthropists (Figure 2) [4, personal communication: C. D. Douglass, Department of Health and Human Services, NIH, Bethesda, MD]. Most industrial research is targeted towards commercially practical products. Research has proved to be so costly that many private foundations have been unable to keep pace and have withdrawn. The tremendous increase in federal support of biomedical education is obvious. Much of the apparent increase

The Amertcan Jwrnal of Surgery

TABLE I

Mortalfty Rates of U.S. Army CasualtIes In w8rS

shlC8

801

1880’

I-

Conflict

Head Injury

chest Wounds

Colon Wounds7

Civil War Spanish-American War World War I Workl War II Korean War Viet Nam War

55.8 30.2 13.9 8.5 7.8 3t

82.8 39.7 24.1 8.3 5.3

*loo f100 66.8 26.5 18.2

3

65-

!

60-

;

55-

6.5

5

50-

75

Data from all but the Viet Nam War was provided by C. Ellsworth (personal communication). Data for the Viet Nam War were taken from [ 71. t The exact mortality rates for colon wounds during the Civil and Spanish-American Wars are unknown but are near 100 percent. t Head and neck injuries. Patients died in hospital in Vlet Nam. 5 Patients died in hospital in Viet Nam.

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in the last several years, however, has simply been keeping in step with inflation (Figure 3, personal communication: C. D. Douglass). The NIH budget in terms of constant dollars (that is, dollars adjusted to inflation) has changed very little. Threats to future support of biomedical research in general: We are in a period in which the economy is generally depressed and in which our government has decided to greatly increase the expenditures for defense. When you put money spent for health research in perspective with federal support for research and development in defense, space, and energy, it is clear that defense-related research has captured a greater share of the prize than ever before (Figure 4) [5]. In the last 15 years, the cost of health care has risen in an almost astronomic fashion (Figure 5) [6]. One way to demonstrate the effect of this great increase is to express the NIH budget as a percent of the total United States expenditure for health. In the last 8 years, the NIH budget has declined from 1.6 to 1.1 percent of the total United States health budget [7].

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The message from the information in Figure 5 is bleak and somewhat ironic. It is clear that health care must not continue to require a larger and larger fraction of the gross national product. Congress and the Social Security Administration have, in fact, prepared drastic remedies, and we will all need to cope with new methods of compensation for health care provided in terms of disease-related groups, a mechanism to provide standard compensation for standard conditions. Ironically, the total amount of money spent for health care has acted to discourage expenditures for health research when such expenditures for research might, in fact, assist in diminishing total health cost. When I was a medical student in Galveston, Texas we had an epidemic of polio almost every summer. Two members of my medical school class died from

MILLIONS s4’Oo -

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FEDERAL INDUSTRY

q PRIVATE TABLE II

Contrlbuttonsof Surgical Research In Order of Importlmnce:1945 to the Present’

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:: 3. 4. 5. 6. 7. t: 10. 11. 12. 13. 14. 15. l

Cardiopulmonary bypass Coronary artery bypass Correctlon of congenltal heart lesions Kidney transplantation Techniques of vascular surgery Intravenous hyperalimentation Hemodialysis Effect of hormones on cancer Improved care of bums Endocrine surgery Metabolic response to trauma Microsurgery techniques Intestinal antisepsis Joint replacement Combined therapy of Wilms’ tumor

Adapted from

[ 41 and enlarged.

Volume 147, January 1984

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polio, and we had in our university hospital, a ward filled with patients in Drinker respirators. Polio caused hundreds of deaths in this country, resulted in paralysis of thousands of patients, and cost our society millions of dollars each year. The grief, terror, and enormous costs of polio all ended with the brilliant work of Salk and Sabin. Many lucid expositions have appeared that clearly show medical research to be highly cost-effective [8-113. Nonetheless, it is clear

that the halcyon days are over. The tremendous research support structure built with great care over the last generation will continue, but there will be a great struggle for appropriations every year and the percentage increase in the NIH budget will be small. Figure 6 shows the percentage of increase in the federal budget for 1984 as compared with 1983 for the Departments of Transportation and Defense as compared with the increase for the NIH [7]. Methods for allocation of research support at the NIH for investigator-initiated research grants (socalled RO-1 grants) has changed greatly. Grants are reviewed by study sections which assign priorities between 100 to 400,100 being the best. A decade ago, most investigators were delighted to receive a priority score of 250, but now the payline (the priority at which grants receive funding) is below 200 (Figure 7, left panel), and in some instances that I know of, grants have been reviewed, assigned a priority of 130, and were still not funded. For many years, about 50 percent of all grants submitted received funding. This percentage has fallen from 50 percent in 1979

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TRANSPORTATION (+ 0126 MILLIONI

DEFENSE (+ 86.7 BILLION)

NATIONAL INSTITUTES OF HEALTH (+ $71 MILLION)

F@rre 6. Fercentage Increases In the ba@ets of Ihe L&qaarMents of Transportation and Defense, compared w/fh those of the National institutes of Health for fiscal year 1984 versus 1983 [ 71.

The American Journal of Surgery

PresidentialAddress

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If the President’s 1984 budget is approved, funding is estimated to fall to 23 percent [7]. We should realize that even with this bad news, the total number of dollars and the total number of grants awarded has increased. The percentage of these awards given to physician investigators, however, has fallen from 34 percent in 1970 to 23 percent in 1980, and the proportion to PhD investigators has risen from 55 to 67 percent (Figure 8) [7]. The number of applications from basic science departments is actually slightly smaller than those from clinical departments, but the number of basic science applications has increased by 22 percent in the last 3 years, as compared with an increase of 17 percent in applications from clinical departments. NIH grant applications from departments of internal medicine constitute 43 percent of all grants from clinical departments, whereas requests from departments of and surgical specialties constitute surgery C. D. only 18 percent [personal communication: Douglass]. Changes in surgical research: When I started my residency at the University of Pennsylvania in 1952, Dr. I. S. Ravdin made it absolutely clear that to succeed, the truest path was through research. Those residents with productive research programs were greatly favored in the tight sweepstakes for the chief residency. All of us are familiar with the great change in emphasis that has occurred. Graduating residents formerly competed smartly for places on the faculty, and the best and the brightest residents

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were always retained by the university. In many programs now, the best and the brightest go into private practice. Some of the reasons for the diminished number of surgical academicians follow. First, of course, the attractiveness of private practice has greatly increased. The general availability of insurance has made surgery lucrative and the percentage of cases that are taken on for charity has greatly diminished. Again, Lewis Thomas [3] noted that at the turn of the century, medicine was not an affluent profession at all; he recalled that his father worked an 80 to 100 hour week to earn a modest living. The tremendous monetary reward is a fairly recent phe-

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Thompson

TABLE III

NIH Grants to Departmentsof Internal Medicine and Surgery in 1873, 1880, and 1982 in Millions of Dollars (SM) and In Percentage of Total NIH Allotments to Medical Schools [4]. 1973

1980

1982

$M

%

$M

%

$M

%

Internal medicine

70.9

21.5

382.3

26.8

409.7

26.9

SW&W All specialties Minus eye 8 ENT specialties

45.4 34.6

13.8 10.5

113.4 75.2

7.9 5.3

125.2 78.3

8.2 5.1

Total

329

100

1,429

100

1,521

100

ENT = ear, nose, and throat.

nomenon. Next, there is the matter of a changing system of rewards. Several things are responsible. The bloom is definitely off the academic peach. Why is that? First, we simply oversold ourselves. We may all remember press conference after press conference in which some internationally famed surgeon would announce that the cure for this or that type of cancer was just around the corner and all that we needed were a few million more dollars. After a while, it became difficult to live up to those promises. Some research ideas made the transition to clinical practice poorly, and bad ideas were often retained too long. As a result of greater competition for financial support in a stressed economy, many research programs were eventually terminated, and medical students and house officers realized that a future career in research might be insecure. Another major factor in the changing system of rewards was the change in the attitudes of medical school administrators toward the earning of money. In the 19509, many deans acted as though making money was an improper or at least an unimportant activity of the faculty, and they celebrated the academic purity of their star investigators. Then, with the loss of private and federal financial support in the 1960s and 19708, medical schools were often driven into hard times and many into fiscal chaos. Looking around urgently for help, some deans realized suddenly that surgeons could bring in a great deal of money, and in many schools, this money-raising capacity was fervently exploited. Surgeons with large practices who had formerly been relegated to the Siberia of medical school society suddenly found themselves elevated to the front ranks of respectability. Promotion committees got the word, and to the great surprise of many, including themselves, persons who previously could not get an instructorship found themselves catapulted into the annointed ranks of professors. Again, medical students and house officers observed and took note. Another factor was the emergence of high quality private programs. This was absolutely predictable. Training programs were designed to turn out highclass practitioners and they did so, and these persons

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went into the community and delivered excellent care. When I was a resident, with the exception of the Mayo Clinic and one or two other institutions, the very best surgery was practiced in university hospitals. That is still true in some cities, but in others there are outstanding private groups, clinics, and hospitals where excellent medicine is practiced. Once again, we cannot minimize the seductive properties of money. Most of us have experienced return visits of house officers who announced gleefully that after 3 to 5 years in practice, they were making more money than anyone on the faculty. We all also recognize that our own activities within ivory halls have not been without blemish. In the last 30 years, the application of research has led to many achievements, some wonderful, some not so wonderful. Many may remember the tremendous number of patients who underwent internal mammary artery ligation for ischemic heart disease before someone took the simple step of performing a random study in which the results of a simple intercostal incision were compared. Gastric freezing was highly touted as treatment for peptic ulcer. I was recently going through an issue of the Surgical Forum from the early 1970s and was surprised to see an entire “Forum” session devoted to reports of freezing. The early widespread application of heart transplantation led to serious problems when technique outreached immunology. Jejunoileal bypass occupied many of us until we realized that it was fruitless to attempt to solve psychiatric problems with surgical procedures. The message is still not recognized universally. Supraradical surgical procedures for cancer of the breast and pelvis are perhaps another example of enthusiasm outreaching knowledge. How is surgical research faring? At the moment, not very well. In 1973, the NIH awarded 21.5 percent of its total research allotment to the departments of internal medicine of medical schools, and the departments of surgery got 13.8 percent (Table III) [4]. If you subtract grants to departments of ophthalmology and ear, nose, and throat surgery, the surgical share is 10.5 percent. By 1982, internal medicine’s portion had increased to almost 27 percent, but

The American Journal of Surgery

Presidential Address

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surgery (exclusive of departments of ophthalmology and ear, nose, and throat surgery) had dropped from 10.5 percent to 5.1 percent. Whereas the percentage of total NIH dollars to departments of internal medicine has increased, the percentage of NIH dollars to departments of surgery has decreased by 50 percent in the last decade. A simple way to document this diminished role of research support is to note the percentage of journal articles that cite sources of financial support for the paper (Figure 9). Curves labeled 1 and 2 show the percentage of articles in two standard surgical journals that gave such citations of research support in 1950 compared with the citations in 1960,1970, and 1980. Curve 3 is a clinical journal in internal medicine and curve 4 is a specialized research journal in a subspecialty of internal medicine. Citations in the surgical journals peaked at less than 40 percent in 1970 and decreased in 1980, whereas citations increased from 1950 to 1970 and remained the same in 1980 in the internal medicine clinical journal and actually increased from 1970 to 1980 in the research journal. What is ahead? It is easy to show that biomedical research in general is in a difficult position because of competition from other segments of our society striving for federal support. The concept that surgical research is in troubIe is absolutely true and we all know it. What can be done? First of all, we should be aware of proposals from basic scientists for allevia: tion of the problem of the falling percentage of approved grants. Several basic science organizations have worked together to suggest a series of proposals

[12]. These organizations advocate adoption of a sliding scale in which the top 50 percent of all reviewed grants would be funded, the budgets for the grants in the top decile would be unchanged, and the budgets of the other grants would be cut on a sliding scale, so that the budgets for the grants in the lowest decile would be decreased by about 60 percent. A second possibility is an across-the-board reduction in all grants in order to cut budgets by 20-40 percent. Another suggestion is to limit the total financial support for any laboratory; that is, to set up an arbitrary limit beyond which no group of investigators would be funded. A fourth suggestion is to distribute a larger fraction of NIH support to investigator-initiated programs (with a consequent .diminution in contracts), and lastly, a ceiling in the spiraling increase in indirect costs is proposed. The main problem in surgery is that we must reattract highly talented persons to careers in research. I am not as pessimistic about this as might be expected. With the great anticipated changes in reimbursement for health care that are suggested by the application of the disease-related group formulas, I suspect that the financial rewards of private practice in the next 10 to 20 years may diminish and academic careers may once again appear more attractive. This may be an academic version of the ill wind. Surgical research has made and will make vital contributions. We must all remember that without surgeons there would be no cardiopulmonary bypass, no transplantation, no joint replacement, and, without total parenteral nutrition, patients with bowel fist&s would still be dying of starvation. There are certainly important challenges that we must still face. Although the death rates for ischemic heart disease have decreased and the death rates for cerebrovascular disease and for accidents are static, the death rates for cancer continue to increase and this should certainly occupy us (Figure 101 [13,14]. Mortality from cancer of the pancreas is increasing

at a fairly rapid rate. Deaths from cancer of the liver are increasing and cancer of the colon and the lung pose unsolved problems. Infection is once again a problem of transcendent importance. Our society has provided us with marvelous tools and has supported the construction of the finest and most productive effort to relieve the scourge of disease that the world has ever seen. Leaders in surgery

must take the responsibility to preserve and rekindle interest in the solution of the tremendous problems of cancer, infection, transplantation, and trauma. If we fail to vigorously pursue research, the medicine and surgery of tomorrow will be the medicine and surgery of today. Acknowledgment: I thank everyone who helped me to prepare this essay. I want particularly to express my gratitude to Alexander C. Bienkowski, Reference Librarian, Moody Medical Library, The University of Texas Medical Branch, Galveston, Texas; Edward N. Brandt, Jr., MD, Assistant Secretary of Health, Department of Health and Human Services, Washington, DC; Carl D. Douglass, PhD, Director, Division of Research Grants, National Institutes of Health, Bethesda, Maryland; Mr. Charles Ellsworth, U.S. Army Center of Military History, Washington, DC; H. George Mandel, PhD, Department of Pharmacology, George Washington University Medical Center, Washington, DC; Marshall J. Orloff, MD, Department of Surgery, University of California, San Diego School of Medicine; Norman M. Rich, MD, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Courtney M. Townsend, Jr., MD, Department of Surgery, The University of Texas Medical Branch, Galveston, Texas; Hugo V. VilIar, MD, Department of Surgery, University of Arizona School of Medicine, Tucson, Arizona, and the staff of the Department of Medical Illustrations, The University of Texas Medical Branch, Galveston, Texas. The summary report of the Study on Surgical Services for the United States [4] was of great help. I also thank my wife, Marilyn A. Thompson, for her advice and for her expert editorial help and Julie Gips for her skilled preparation of the manuscript.

References 1.

Hardaway RM III.Viet Nam wound analysis. J Trauma 1978;

18~835-43. 2. National Center for Health Statistics, U.S. Department of Health and Human Services. Statistical abstract of the United States, 102 ed, Washington, DC: U.S. Government Printing Office, 1981:958. 3. Thomas L. The youngest science. Notes of a medicine-watcher. New York: Viking Press, 1983. 4. Surgery in the United States. A summary report of the study on surgical services for the United States. Vol. II. Chicago: American College of Surgeons and the American Surgical Association, 1976:1437-691. 5. U.S. National Science Foundation, Federal funds for research and development, annual. Statistical abstract of the United States, 102 Ed. Washington, DC: U.S. Government Printing Office, 1981: 800. 6. Office of Research, Demonstrations, and Statistics: National health expenditures, 1980. Gibson RM, Waldo DR, eds. Health care financing review. HCFA Pub. No. 03123. Health Care Financing Administration. Washington, DC: U.S. Government Printing Office, 1981. 7. Health Research. A proposal for FY 1984. National Institutes of Health, March 1963. Prepared by the Association of American Medical Colleges. Coordinated by Ann Stanley. 8. Mushkin SJ. Biomedical research: cost and benefits. Cambridge, MA: Ballinger, 1979:407-15. 9. Thomas L. On the science and technology of medicine. In: Knowles JH, ed. Doing better and feeling worse. Health in the United States. New York: WW Norton, 1977. 10. Schneyer S, Landefeld JS, Sandifer FH. Biomedical research and illness: 1900-1979. Millbank Memorial Fund Quarterly, 1981. 11. Comroe JH Jr, Dripps RD. Scientific basis for the support of biomedical science: In: Roberts EB, Levy RI, Finkelstein SN, Moskowitz J, Sondik EJ, eds. Biomedical innovation. Cambridge, MA: MIT Press, 1981, 101-22. 12. Mandel HG. Funding more NIH research grants. Proposals of a multidisciplinary group of biomedical scientists. Science 1983;221:338-40. 13. U.S. National Center for Health Statistics, Vital statistics of the United States, annual. In: Statistical abstract of the United States, 102 ed. Washinton, DC: U.S. Government Printing Office. 1981:74. 14. U.S. Bureau of the Census, Census of population, 1970. In: Statistical abstract of the United States, 102 Ed. Washington, DC: U.S. Government Printing Office, 1981:lO.

The Am&can Journal of Surgery