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The Southwestern Surgical story
PRESIDENTIAL ADDRESS
The Southwestern Surgical Story
Albert J. Kukral, MD, Lakewood, Colorado
President Southwestern Surgical Congress
Of all my associations with surgical societies, none have grown dearer or closer to me than the Southwestern Surgical Congress. It is for this reason that I am particularly honored and proud to have had the privilege to serve as your president during the past year. I am grateful for that opportunity and I shall always cherish that memory. I was encouraged to become involved in this society by two close Denver friends and past presidents, Drs. Robert Spencer and the late Howard Robertson-I am happy they did. When it occurred to me that a brief historic review From the Surgical Services, St. Josephs arki St. Anthonys Lutheran Hospitals, Denver, Colorado. Requests for reprints should be addressed to Albert J. Kukral, MD, Woodridge Medical Building, Suite 15-A, 2020 Wadsworth Boulevard, Lakewood, Colorado 80215. Presented at the 34th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1982.
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of the Southwestern Surgical Congress might be of interest to you, I was unaware that our past President, Dr. John Growdon, presented a similar topic. Hopefully, my address will not be too repetitious. I have spent several days perusing the voluminous correspondence and records of deliberations which went into the formation of our Congress. Now, let me share some of the highlights with you. In April 1948, at the 20th Annual Meeting of the Southeastern Surgical Congress in Miami, Drs. R. L. Sanders of Memphis, and B. T. Beasley of Atlanta, suggested to Dr. Walter Stuck of San Antonio the need for a regional surgical group for the surgeons of the Southwest. At the same time, Drs. Good (Texarkana), Overton (Albuquerque), Cogswell (Tucson), and Goode (Dallas) has organized a meeting for a similar purpose. Their objectives being the same, the two groups merged. Dr. Charles Roundtree (Oklahoma
The American Journal of Surgery
The Southwestern
City) invited 21 surgeons representing town and gown from six states, Arizona, Arkansas, Missouri, New Mexico, Oklahoma, and Texas, to the first organizational meeting of the Southwestern Surgical Congress, held at the Skirvin Hotel on October 3, 1.948. Five Southeastern Surgical officers were also invited, and were instrumental in the formation of the Southwestern Surgical Congress. One has only to see the prodigious volume of correspondence between all of these gentlemen to appreciate the tremendous enthusiasm of the Southwestern surgeons, and the encouragement and support offered by the Southeastern surgeons. At the time, there were approximately 2,300 surgeons in the Southwest Territory, which was comprised of nine states west of the Mississippi River and south of the Mason-Dixon line: Arizona, Arkansas, Colorado, Kansas, Missouri, New Mexico, Oklahoma, Texas, and Utah. Of these 2,300 surgeons, approximately 1,700 were fellows in the American College of Surgeons, and less than 100 were affiliated with the American, Western, or Southern Surgical Societies. This left at least 1,600 well qualified surgeons with no place “to hang their hats.” This need spawned the beginning of the Southwestern Surgical Congress. At the first organizational meeting, Dr. Walter Stuck was elected temporary chairman and later, president, and Dr. Charles R. Roundtree, temporary secretary and later, secretary-treasurer. In addition, one representative from each participating state (councillor) was elected to promote the new society in his respective state. The aims and goals of the Southwestern Surgical Congress as written by Dr. Louis Good in the July 1949 issue of the Southern Surgeon were as follows: (1) To seek out the talent in young surgeons, encourage and promote its development, and make live in these individuals the realization that they are part of a great practicing-teaching group, not only at the annual meeting but year-round. (2) To encourage and seek out special talents in the young practicing surgeon. (3) To keep statistical records of his work. (4) To promote the registry of rare and unusual cases. Dr. Good stated that one should beware of the man who reports only a single case; however, if all the members report and submit their rare cases, soon a sufficient number would be compiled to be an interesting and informative report for a paper. (5) To start and maintain a slide museum of microscopic and gross specimens. To depict the cordiality of the Southeastern Surgical Society, let me quote from an article written by Dr. Sanders in the December 1948 issue of The Southern Surgeon: “Greetings to the Southwestern Surgical Congress: The surgeons of the Great West in historic fashion, have undertaken to blaze a wide new trail for the advancement of surgery in the farflung regions which comprise their section of the country. This new surgical society is the outgrowth
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of a real need.” (It reads like a page out of Zane Grey’s of the West, doesn’t it?) The second meeting was convened again in Oklahoma City, on April 10, 1949, with 49 surgeons attending. Three new charter states, Colorado, Kansas, and Utah, were represented. Constitution and bylaws were presented and adopted, stipulating that membership be open to any reputable and trained surgeon in the southwest geographic area who is recommended by his state executive council. Today, our Congress still welcomes any properly endorsed, ethical board-certified surgeon. Plans were also presented for the first annual scientific meeting to be held in September 1949 at the Shamrock Hotel in Houston, Texas. Dr. Walter Stuck presided and Dr. Louis Good was the program chairman. Of a total membership of approximately 850 persons, 601 (medical doctors and their spouses) registered. That first meeting was one of our largest. Compare that membership to our present one of approximately 1,500 with approximately 500 registered. At the first annual business meeting, the participants reached above the MasonDixon Line and accepted Wyoming as the 10th state for membership. That move opened the door for Nebraska, Nevada, and Montana to be added as the llth, 12th and 13th states in 1961,1962, and 1973, respectively. About 1 month after the first annual meeting on October 5,1949, Dr. Stuck wrote to Dr. Sanders the following: “I think your brainchild is very lusty. Everyone has been raging about the new Southwestern Surgical Congress. You and I know that it was principally your doing, and we certainly appreciate it.” He goes on: “I must say that 2 years ago (that is, 1947) I was not too sure that this idea would go over. Now I realize that you certainly knew what you were talking about.” His words indicate that the first mention of the Southwestern Surgical Congress was actually made in 1947. Dr. Thomas G, Orr (Kansas) presided at the second annual scientific session in September 1950 in Denver, Colorado. He was to be later (May 9,1965) distinguished by having a memorial lectureship established in his honor. (He died November 19,1955.) Dr. Michael DeBakey delivered the first oration in 1966. (This year it will be presented by another Kansan, Dr. Arlo Hermreck.) At the 1950 meeting, the first official address of our society, 1227 Classen Street, Oklahoma City, was announced, and Miss June Marchant was hired as the first part-time lay secretary. Dr. Walter Stuck, our first president, died shortly before the second annual meeting. The new idea of considering case reports with only a few exceptional ones being accepted as 3 to 5 minute presentations was proposed and implemented. Several years ago, the council voted to have the poster sessions replace these case reports. Originally, there were as many as six guest speakers at the annual meetings from outside the SouthSaga
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west Territory. However, as the years went on, the emphasis was on fewer guest speakers and more participation by our fellows. Although I agree with more participation by our members, two “visiting firemen” from outside the territory each year, I believe, add a nice dimension to our meetings. I hope our Society sees fit to continue that policy. Whereas every organization needs “new blood,” I maintain that while our organization should always remain open to any board-certified and reputable surgeon, numbers should not be our main goal. Rather, we should be selective and solicit those truly interested in our society, and those who will become involved, at least to the extent of attending our scientific sessions and presenting abstracts. In my review of the council deliberations, I was struck by what appeared to be an inordinate amount of time devoted to the selection of an official journal. Obviously, the matter of publication is vital to any organization. In 1950 The Southern Surgeon became the official publication of both the Southeastern and Southwestern Surgical Congresses. Shortly thereafter (July 1, 1951) joint ownership was proposed, and consumated and the journal was renamed The American Surgeon, with Dr. T. G. Orr as editor. The relationship with the publishers, however, was punctuated by frequent and often unpleasant turbulent hassles over deficits and costs of publishing and so forth. Finally, in 1963, The American Journal of Surgery, edited by Dr. Robert M. Zollinger, became and remains our official publication. Dr. Michael DeBakey presided at our fourth annual meeting in 1952. That meeting produced the printing of our first bylaws, roster of membership, and a request for representation on the Board of Governors of The American College of Surgeons. The College indicated that they would entertain a seat for us when more than 50 percent of our members were fellows and when our rigid membership requirements were enforced. This was realized in 1963, when Dr. Edgar Poth was appointed governor to the College. There were four previous historians, but it was not until 1980 that the post of historian was officially established with Dr. Cyril Costello (St. Louis) appointed to that office. The subject of commercial exhibits was discussed for the first time in 1954, and the council opted not to incorporate them into our scientific meetings. This was reviewed on many occasions, and each time the consensus was that the society should not be extensively involved with commercial exhibits, especially if they compete with our scientific program. A new problem of declining attendance was addressed at the April 1955 council meeting. It was noted that only 25 percent of the membership attended the previous annual meeting; however, this was not unique to 1954. It has been observed and discussed many times since, and we still note the same experience today. Nonetheless, several solu602
tions were offered: One was an “Illustrated Hour” prepared by the university centers within the geographic area or in the town hosting the scientific program. The surgical departments of these institutions presented a program of their own choosing and format, which was very well received. The first schools participating in the September 1955 annual meeting in Kansas City, Missouri were St. Louis, Kansas, and Washington Universities. I could find no similar format in any subsequent scientific session. Personally, I feel that we should revisit this concept. To involve the university medical centers with the practicing surgeons in the community, and thus strengthen the bond between these two equally important and dedicated disciplines would be mutually beneficial. Another solution was proposed in 1957 by Dr. Starry of Oklahoma City, when he presented an innovative idea: the Scientific Essay Award Contest. Any resident from the Southwest who had completed his first year was encouraged to submit an abstract. The three best papers would then be selected to be presented at our scientific session, with cash prizes being awarded to the first, second, and third place winners. Dr. John R. Schwartzmann, now of Mesa, Arizona, was the first chairman of the Scientific Essay Award Contest Committee, and the first Essay Award papers were delivered in 1959. To further encourage participation at our meetings, the topic of “rejected manuscripts” was discussed. It was suggested that these rejected papers be “read by title” at the meeting and listed in the printed program. The authors of these rejected papers were encouraged to submit their manuscript to the Journal for publication. In an effort to make our meetings more attractive, the concept of sectioning the scientific program was employed. We still follow that format, with presentations being grouped together according to their specialty. This permits an in-depth presentation of a single topic on a given day, as is required to maintain CME accreditation. Because our fall meeting dates conflicted with other society meetings, we held our first spring session in April 1956, in Tucson, Arizona. In the following decade, our prolific councils proposed more firsts and innovations. The first instance in which our society took a stand on a political issue was in 1963. We sent a copy of a resolution to several United States congressmen which indicated our opposition to proposed Federal legislation that called for stringent regulations in scientific experiments using animals. We cited that it would be unfavorable to the progress of biologic sciences, would deter advancement in the treatment of human illness, and would cause undue restrictions on the freedom of research enterprise. To add a bit of levity to our meetings, the first mention of an organized golf tournament was made in 1964. A few moments ago, you heard me mention the Scientific Essay Award Contest. As a spin-off from this concept, a sponsored resident program was inThe American Journal of Surgery
The Southwestern Surgical Story
augurated to broaden resident participation. Any surgical resident affiliated with an approved program could be sponsored, either by his chief, or by one of our fellows, to attend and/or participate in our meeting. The Congress hosted 13 residents at the first residents’ breakfast in 1964 at the San Antonio meeting. We continue to welcome residents attending our meetings to this breakfast, which is traditionally held at 7:00 A.M.on a Monday. It is noteworthy that many of the original 13 became, and still are, members of the Southwestern Surgical Congress. Among those is Dr. Orville Rickey, formerly a councillor from the state of Oklahoma, chairman of the sponsored Resident Program Committee, and currently still a very active member of our organization. The first sponsored resident paper was delivered at our 1!366 meeting in Las Vegas. Presently, about one third of our presentations are delivered by residents. I know of no other organization that fosters such a worthwhile program. It is our pride and joy! In that same year, a society-wide Clinical Study Committee was formed. Its task was to evaluate any protocol submitted by the membership, and to determine the most significant clinical study to be undertaken. All members were invited and encouraged to participate. It was felt that much good data could be harvested. I could find no such study ever initiated. I wonder if such a committee should be reconsidered7 In 1965 the tine clinics were first introduced as part of our program, and the Publication and Research Committee was formed with Dr. Poth as chairman. Dr. Jack Barney was introduced as a guest of the council at the April 17,1966 meeting. Later at that meeting, he was elected secretary-treasurer, and he still holds that position. At the same meeting it was proposed to seek representation on The American Board of Surgery, We were informed at the time that there was no need for additional sponsoring organizations; however, I would like to see our society continue in its quest for representation. The question was asked in 1969 whether membership requirements should stipulate board certification-mandatory certification was finally approved in 1975. Once again, discussion ensued as to whether the Southeastern and Southwestern Surgical Congresses should hold a joint meeting. It was judged to be impractical by consensus; however, I believe we should pursue this as a nice gesture, if for no other reason than historic purposes, since the Southeastern Surgical Congress was so instrumental in our formation. During a recent conversation with Dr. Letton, Secretary of the Southeastern Surgical Congress, he indicated that it might be a fine and plausible idea; particularly since both of our meetings are held in the spring, He promised to bring this before his council, and suggested perhaps a joint meeting in New Orleans would be best. This can be pursued by our future Annual Meeting Committee. Periodically, we honor one of our dedicated fellows, and so, in 1974, the second Southwestern Surgical Volume 144, December 1992
Lectureship was established in the name of Dr. Edgar J. Poth. This oration was first delivered by Dr. George Mertz as his presidential address in 1975. Another touch of class was added in 1978 when a private court reporter was hired to transcribe the discussions at our meeting. They are now published as a fine addition to our publications. More good news was announced: As of September 1978, our meetings were approved for Category 1 CME accreditation for 4 years. To keep our members informed on the vital issues of the day, in 1980 the council approved an issueoriented lecture to be delivered at our scientific sessions. We will hear our second such presentation during this meeting. If we are informed, we will be able to speak out and take a stand. This review of the highlights of our history has briefly covered the past and brought us up to the present. Now, in the remaining short time, let us ponder what the Southwestern Surgical Congress can contribute to the future of medicine. Certainly, we should continue to perpetuate the aims, goals, and ideals of our society. As the third largest surgical organization, it is incumbent on us to make our views known, and to take a stand when appropriate. Let us reexamine the state of the art in the practice of surgery. Although there are many areas which can be addressed, I shall mention only a few. Are we training our surgeons to be qualified complete general surgeons today or are such persons a vanishing breed? Are the various subspecialties, inside and outside the realm of surgery, developing, by fiat, “territorial imperatives,” and thus eroding the ability of the general surgeon to totally assess and care for his patient? Should not our residency programs include training in the various endoscopic procedures? Such capability would afford the benefit of viewing and assessing the extent and character of local pathology, and it should be the sine qua non for the operating surgeon, so that the wisest judgment can be made when and if further surgical efforts are indicated. Moreover, who is better qualified than the surgeon to intervene if complications in these procedures occur? Also, I sense that better cost containment could be achieved. I am pleased to hear that The American Board of Surgery is considering to make it mandatory that these parameters be included in all approved surgical training programs. I also hope the Board makes other recommendations to obviate genera.1 surgery from becoming merely “residual surgery.” Another concern that seems to be emerging is the trend to exclude the operating surgeon from the total postoperative care of his patient. I am alluding to the operated patient being delivered to a critical care area, and his case being taken over by an “intensivist.” Although these patients do require careful monitoring, most trained surgeons should be capable of assessing and relating to the data gathered by the intensive care nurse, and making the appropriate 603
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decisions. After all, did the surgeon suddenly become inadequate for this task, when only a short while ago, as chief resident, he probably supervised the same critical care area? Let us keep this in proper perspective and not abdicate our doctor-patient relationship. About 15 years ago fears surfaced, principally in the government and consumer sectors, that medical manpower would soon be critically deficient. Accordingly, medical school enrollments mushroomed. Presently on the horizon, we see a burgeoning surplus of doctors. In this plethora we find ourselves training more and more surgeons. Could a surfeit of underemployed surgeons be a factor in the allegation that unnecessary surgery is being performed? We know there is no manpower shortage, but rather the problem lies in the distribution of talent. The hackneyed issue of cost containment must be constantly reviewed, despite the fact that excellent articles on the subject abound. With the explosion of medical technology, we must discipline ourselves to employ only those parameters that materially add to the evaluation of our patients. A graphic example of this concept is poignantly illustrated in the New England Journal of Medicine’s Clinicopathologic Conference of February 11, 1982. Will the surgical second opinion have a salutory effect on cost containment? Overutilization: Albeit a worked-over problem, it is still with us. Recently in one of our hospitals a simple profile relating to 50 routine, uncomplicated cholecystectomies performed by 13 surgeons on relatively healthy patients, revealed a $1,300 differential in hospital charges, with many as high as $800 above the mean. This was chiefly due to length of hospital stay and postoperative laboratory determinations. I dare say this finding can be echoed in many hospitals across the nation and undoubtedly applies to many other other routine procedures. Findings of this kind prompted the introduction of diagnostic-related groups which serve as a mechanism by which one can prescribe a.fixed prospective fee structure for hospital-patient care reimbursement. Presently, there are approximately 385 diagnostic-related groups pegged into the program which are aggregates of patients based on age, principal and secondary diagnoses, and principal and secondary procedures. New Jersey has already implemented this program,
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and many states are considering following suit if the newly formed coalition of medicine, business, hospital, insurance, and labor is not more successful at containing costs in the very near future. We physicians must hear the clear signal issued from Washington, DC, that physicians’ fixed prospective reimbursements may be the next consideration, unless we offer viable alternatives. Since the malpractice crisis in the early 197Os, the concept of “defensive medicine” has become manifest. We all recognize its presence; however, it is difficult to identify and quantify its impact on the quality and cost of medical care. Fear of suit escalates cost by overutilization of diagnostic and therapeutic procedures that are not medically necessary. Agencies within the Department of Health and Human Services are seriously considering guidelines for certain procedures which must be performed in an ambulatory outpatient setting in order to be compensated. Already in Colorado, the Department of Social Services has mandated such a program for Medicaid patients. We should applaud the various pioneer surgicenters of Phoenix (Wallace Reed Surgicenter) and Salt Lake City. This is simply another example of why haven’t we addressed the problem and rectified it before the government agencies “forced the issue”? Can we assuage some of these vexing problems? I believe we can and must if we wish to remain one of the last bastions of individual enterprise-to say nothing about improving our image with the consumer. If we don’t, we can be assured that outside nonmedical agencies will do the shepherding. Two forces are available: first, the individual grassroots effort of each of us in our daily doctor-patient contact, and second, the concerted effort by the entire surgical sector. We must present a united front and speak as one through our organization. Since its inception, the Southwestern Surgical Congress has enjoyed a healthy and conversant relationship between “town and gown,” Each group is equally dedicated to his sphere of surgery and each is where he is because he feels more comfortable and productive there. We must strive to maintain a good balance of these two groups, as has been exhorted many times in our society. These are then, but a few challenges facing us: ones I feel confident we can measure up to.
The American Journal of Surgery
The Southwestern Surgical Story
Albert J. Kukral, MD, Lakewood, Colorado
President Southwestern Surgical Congress
Of all my associations with surgical societies, none have grown dearer or closer to me than the Southwestern Surgical Congress. It is for this reason that I am particularly honored and proud to have had the privilege to serve as your president during the past year. I am grateful for that opportunity and I shall always cherish that memory. I was encouraged to become involved in this society by two close Denver friends and past presidents, Drs. Robert Spencer and the late Howard Robertson-I am happy they did. When it occurred to me that a brief historic review From the Surgical Services, St. Josephs arki St. Anthonys Lutheran Hospitals, Denver, Colorado. Requests for reprints should be addressed to Albert J. Kukral, MD, Woodridge Medical Building, Suite 15-A, 2020 Wadsworth Boulevard, Lakewood, Colorado 80215. Presented at the 34th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1982.
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of the Southwestern Surgical Congress might be of interest to you, I was unaware that our past President, Dr. John Growdon, presented a similar topic. Hopefully, my address will not be too repetitious. I have spent several days perusing the voluminous correspondence and records of deliberations which went into the formation of our Congress. Now, let me share some of the highlights with you. In April 1948, at the 20th Annual Meeting of the Southeastern Surgical Congress in Miami, Drs. R. L. Sanders of Memphis, and B. T. Beasley of Atlanta, suggested to Dr. Walter Stuck of San Antonio the need for a regional surgical group for the surgeons of the Southwest. At the same time, Drs. Good (Texarkana), Overton (Albuquerque), Cogswell (Tucson), and Goode (Dallas) has organized a meeting for a similar purpose. Their objectives being the same, the two groups merged. Dr. Charles Roundtree (Oklahoma
The American Journal of Surgery
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City) invited 21 surgeons representing town and gown from six states, Arizona, Arkansas, Missouri, New Mexico, Oklahoma, and Texas, to the first organizational meeting of the Southwestern Surgical Congress, held at the Skirvin Hotel on October 3, 1.948. Five Southeastern Surgical officers were also invited, and were instrumental in the formation of the Southwestern Surgical Congress. One has only to see the prodigious volume of correspondence between all of these gentlemen to appreciate the tremendous enthusiasm of the Southwestern surgeons, and the encouragement and support offered by the Southeastern surgeons. At the time, there were approximately 2,300 surgeons in the Southwest Territory, which was comprised of nine states west of the Mississippi River and south of the Mason-Dixon line: Arizona, Arkansas, Colorado, Kansas, Missouri, New Mexico, Oklahoma, Texas, and Utah. Of these 2,300 surgeons, approximately 1,700 were fellows in the American College of Surgeons, and less than 100 were affiliated with the American, Western, or Southern Surgical Societies. This left at least 1,600 well qualified surgeons with no place “to hang their hats.” This need spawned the beginning of the Southwestern Surgical Congress. At the first organizational meeting, Dr. Walter Stuck was elected temporary chairman and later, president, and Dr. Charles R. Roundtree, temporary secretary and later, secretary-treasurer. In addition, one representative from each participating state (councillor) was elected to promote the new society in his respective state. The aims and goals of the Southwestern Surgical Congress as written by Dr. Louis Good in the July 1949 issue of the Southern Surgeon were as follows: (1) To seek out the talent in young surgeons, encourage and promote its development, and make live in these individuals the realization that they are part of a great practicing-teaching group, not only at the annual meeting but year-round. (2) To encourage and seek out special talents in the young practicing surgeon. (3) To keep statistical records of his work. (4) To promote the registry of rare and unusual cases. Dr. Good stated that one should beware of the man who reports only a single case; however, if all the members report and submit their rare cases, soon a sufficient number would be compiled to be an interesting and informative report for a paper. (5) To start and maintain a slide museum of microscopic and gross specimens. To depict the cordiality of the Southeastern Surgical Society, let me quote from an article written by Dr. Sanders in the December 1948 issue of The Southern Surgeon: “Greetings to the Southwestern Surgical Congress: The surgeons of the Great West in historic fashion, have undertaken to blaze a wide new trail for the advancement of surgery in the farflung regions which comprise their section of the country. This new surgical society is the outgrowth
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of a real need.” (It reads like a page out of Zane Grey’s of the West, doesn’t it?) The second meeting was convened again in Oklahoma City, on April 10, 1949, with 49 surgeons attending. Three new charter states, Colorado, Kansas, and Utah, were represented. Constitution and bylaws were presented and adopted, stipulating that membership be open to any reputable and trained surgeon in the southwest geographic area who is recommended by his state executive council. Today, our Congress still welcomes any properly endorsed, ethical board-certified surgeon. Plans were also presented for the first annual scientific meeting to be held in September 1949 at the Shamrock Hotel in Houston, Texas. Dr. Walter Stuck presided and Dr. Louis Good was the program chairman. Of a total membership of approximately 850 persons, 601 (medical doctors and their spouses) registered. That first meeting was one of our largest. Compare that membership to our present one of approximately 1,500 with approximately 500 registered. At the first annual business meeting, the participants reached above the MasonDixon Line and accepted Wyoming as the 10th state for membership. That move opened the door for Nebraska, Nevada, and Montana to be added as the llth, 12th and 13th states in 1961,1962, and 1973, respectively. About 1 month after the first annual meeting on October 5,1949, Dr. Stuck wrote to Dr. Sanders the following: “I think your brainchild is very lusty. Everyone has been raging about the new Southwestern Surgical Congress. You and I know that it was principally your doing, and we certainly appreciate it.” He goes on: “I must say that 2 years ago (that is, 1947) I was not too sure that this idea would go over. Now I realize that you certainly knew what you were talking about.” His words indicate that the first mention of the Southwestern Surgical Congress was actually made in 1947. Dr. Thomas G, Orr (Kansas) presided at the second annual scientific session in September 1950 in Denver, Colorado. He was to be later (May 9,1965) distinguished by having a memorial lectureship established in his honor. (He died November 19,1955.) Dr. Michael DeBakey delivered the first oration in 1966. (This year it will be presented by another Kansan, Dr. Arlo Hermreck.) At the 1950 meeting, the first official address of our society, 1227 Classen Street, Oklahoma City, was announced, and Miss June Marchant was hired as the first part-time lay secretary. Dr. Walter Stuck, our first president, died shortly before the second annual meeting. The new idea of considering case reports with only a few exceptional ones being accepted as 3 to 5 minute presentations was proposed and implemented. Several years ago, the council voted to have the poster sessions replace these case reports. Originally, there were as many as six guest speakers at the annual meetings from outside the SouthSaga
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west Territory. However, as the years went on, the emphasis was on fewer guest speakers and more participation by our fellows. Although I agree with more participation by our members, two “visiting firemen” from outside the territory each year, I believe, add a nice dimension to our meetings. I hope our Society sees fit to continue that policy. Whereas every organization needs “new blood,” I maintain that while our organization should always remain open to any board-certified and reputable surgeon, numbers should not be our main goal. Rather, we should be selective and solicit those truly interested in our society, and those who will become involved, at least to the extent of attending our scientific sessions and presenting abstracts. In my review of the council deliberations, I was struck by what appeared to be an inordinate amount of time devoted to the selection of an official journal. Obviously, the matter of publication is vital to any organization. In 1950 The Southern Surgeon became the official publication of both the Southeastern and Southwestern Surgical Congresses. Shortly thereafter (July 1, 1951) joint ownership was proposed, and consumated and the journal was renamed The American Surgeon, with Dr. T. G. Orr as editor. The relationship with the publishers, however, was punctuated by frequent and often unpleasant turbulent hassles over deficits and costs of publishing and so forth. Finally, in 1963, The American Journal of Surgery, edited by Dr. Robert M. Zollinger, became and remains our official publication. Dr. Michael DeBakey presided at our fourth annual meeting in 1952. That meeting produced the printing of our first bylaws, roster of membership, and a request for representation on the Board of Governors of The American College of Surgeons. The College indicated that they would entertain a seat for us when more than 50 percent of our members were fellows and when our rigid membership requirements were enforced. This was realized in 1963, when Dr. Edgar Poth was appointed governor to the College. There were four previous historians, but it was not until 1980 that the post of historian was officially established with Dr. Cyril Costello (St. Louis) appointed to that office. The subject of commercial exhibits was discussed for the first time in 1954, and the council opted not to incorporate them into our scientific meetings. This was reviewed on many occasions, and each time the consensus was that the society should not be extensively involved with commercial exhibits, especially if they compete with our scientific program. A new problem of declining attendance was addressed at the April 1955 council meeting. It was noted that only 25 percent of the membership attended the previous annual meeting; however, this was not unique to 1954. It has been observed and discussed many times since, and we still note the same experience today. Nonetheless, several solu602
tions were offered: One was an “Illustrated Hour” prepared by the university centers within the geographic area or in the town hosting the scientific program. The surgical departments of these institutions presented a program of their own choosing and format, which was very well received. The first schools participating in the September 1955 annual meeting in Kansas City, Missouri were St. Louis, Kansas, and Washington Universities. I could find no similar format in any subsequent scientific session. Personally, I feel that we should revisit this concept. To involve the university medical centers with the practicing surgeons in the community, and thus strengthen the bond between these two equally important and dedicated disciplines would be mutually beneficial. Another solution was proposed in 1957 by Dr. Starry of Oklahoma City, when he presented an innovative idea: the Scientific Essay Award Contest. Any resident from the Southwest who had completed his first year was encouraged to submit an abstract. The three best papers would then be selected to be presented at our scientific session, with cash prizes being awarded to the first, second, and third place winners. Dr. John R. Schwartzmann, now of Mesa, Arizona, was the first chairman of the Scientific Essay Award Contest Committee, and the first Essay Award papers were delivered in 1959. To further encourage participation at our meetings, the topic of “rejected manuscripts” was discussed. It was suggested that these rejected papers be “read by title” at the meeting and listed in the printed program. The authors of these rejected papers were encouraged to submit their manuscript to the Journal for publication. In an effort to make our meetings more attractive, the concept of sectioning the scientific program was employed. We still follow that format, with presentations being grouped together according to their specialty. This permits an in-depth presentation of a single topic on a given day, as is required to maintain CME accreditation. Because our fall meeting dates conflicted with other society meetings, we held our first spring session in April 1956, in Tucson, Arizona. In the following decade, our prolific councils proposed more firsts and innovations. The first instance in which our society took a stand on a political issue was in 1963. We sent a copy of a resolution to several United States congressmen which indicated our opposition to proposed Federal legislation that called for stringent regulations in scientific experiments using animals. We cited that it would be unfavorable to the progress of biologic sciences, would deter advancement in the treatment of human illness, and would cause undue restrictions on the freedom of research enterprise. To add a bit of levity to our meetings, the first mention of an organized golf tournament was made in 1964. A few moments ago, you heard me mention the Scientific Essay Award Contest. As a spin-off from this concept, a sponsored resident program was inThe American Journal of Surgery
The Southwestern Surgical Story
augurated to broaden resident participation. Any surgical resident affiliated with an approved program could be sponsored, either by his chief, or by one of our fellows, to attend and/or participate in our meeting. The Congress hosted 13 residents at the first residents’ breakfast in 1964 at the San Antonio meeting. We continue to welcome residents attending our meetings to this breakfast, which is traditionally held at 7:00 A.M.on a Monday. It is noteworthy that many of the original 13 became, and still are, members of the Southwestern Surgical Congress. Among those is Dr. Orville Rickey, formerly a councillor from the state of Oklahoma, chairman of the sponsored Resident Program Committee, and currently still a very active member of our organization. The first sponsored resident paper was delivered at our 1!366 meeting in Las Vegas. Presently, about one third of our presentations are delivered by residents. I know of no other organization that fosters such a worthwhile program. It is our pride and joy! In that same year, a society-wide Clinical Study Committee was formed. Its task was to evaluate any protocol submitted by the membership, and to determine the most significant clinical study to be undertaken. All members were invited and encouraged to participate. It was felt that much good data could be harvested. I could find no such study ever initiated. I wonder if such a committee should be reconsidered7 In 1965 the tine clinics were first introduced as part of our program, and the Publication and Research Committee was formed with Dr. Poth as chairman. Dr. Jack Barney was introduced as a guest of the council at the April 17,1966 meeting. Later at that meeting, he was elected secretary-treasurer, and he still holds that position. At the same meeting it was proposed to seek representation on The American Board of Surgery, We were informed at the time that there was no need for additional sponsoring organizations; however, I would like to see our society continue in its quest for representation. The question was asked in 1969 whether membership requirements should stipulate board certification-mandatory certification was finally approved in 1975. Once again, discussion ensued as to whether the Southeastern and Southwestern Surgical Congresses should hold a joint meeting. It was judged to be impractical by consensus; however, I believe we should pursue this as a nice gesture, if for no other reason than historic purposes, since the Southeastern Surgical Congress was so instrumental in our formation. During a recent conversation with Dr. Letton, Secretary of the Southeastern Surgical Congress, he indicated that it might be a fine and plausible idea; particularly since both of our meetings are held in the spring, He promised to bring this before his council, and suggested perhaps a joint meeting in New Orleans would be best. This can be pursued by our future Annual Meeting Committee. Periodically, we honor one of our dedicated fellows, and so, in 1974, the second Southwestern Surgical Volume 144, December 1992
Lectureship was established in the name of Dr. Edgar J. Poth. This oration was first delivered by Dr. George Mertz as his presidential address in 1975. Another touch of class was added in 1978 when a private court reporter was hired to transcribe the discussions at our meeting. They are now published as a fine addition to our publications. More good news was announced: As of September 1978, our meetings were approved for Category 1 CME accreditation for 4 years. To keep our members informed on the vital issues of the day, in 1980 the council approved an issueoriented lecture to be delivered at our scientific sessions. We will hear our second such presentation during this meeting. If we are informed, we will be able to speak out and take a stand. This review of the highlights of our history has briefly covered the past and brought us up to the present. Now, in the remaining short time, let us ponder what the Southwestern Surgical Congress can contribute to the future of medicine. Certainly, we should continue to perpetuate the aims, goals, and ideals of our society. As the third largest surgical organization, it is incumbent on us to make our views known, and to take a stand when appropriate. Let us reexamine the state of the art in the practice of surgery. Although there are many areas which can be addressed, I shall mention only a few. Are we training our surgeons to be qualified complete general surgeons today or are such persons a vanishing breed? Are the various subspecialties, inside and outside the realm of surgery, developing, by fiat, “territorial imperatives,” and thus eroding the ability of the general surgeon to totally assess and care for his patient? Should not our residency programs include training in the various endoscopic procedures? Such capability would afford the benefit of viewing and assessing the extent and character of local pathology, and it should be the sine qua non for the operating surgeon, so that the wisest judgment can be made when and if further surgical efforts are indicated. Moreover, who is better qualified than the surgeon to intervene if complications in these procedures occur? Also, I sense that better cost containment could be achieved. I am pleased to hear that The American Board of Surgery is considering to make it mandatory that these parameters be included in all approved surgical training programs. I also hope the Board makes other recommendations to obviate genera.1 surgery from becoming merely “residual surgery.” Another concern that seems to be emerging is the trend to exclude the operating surgeon from the total postoperative care of his patient. I am alluding to the operated patient being delivered to a critical care area, and his case being taken over by an “intensivist.” Although these patients do require careful monitoring, most trained surgeons should be capable of assessing and relating to the data gathered by the intensive care nurse, and making the appropriate 603
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decisions. After all, did the surgeon suddenly become inadequate for this task, when only a short while ago, as chief resident, he probably supervised the same critical care area? Let us keep this in proper perspective and not abdicate our doctor-patient relationship. About 15 years ago fears surfaced, principally in the government and consumer sectors, that medical manpower would soon be critically deficient. Accordingly, medical school enrollments mushroomed. Presently on the horizon, we see a burgeoning surplus of doctors. In this plethora we find ourselves training more and more surgeons. Could a surfeit of underemployed surgeons be a factor in the allegation that unnecessary surgery is being performed? We know there is no manpower shortage, but rather the problem lies in the distribution of talent. The hackneyed issue of cost containment must be constantly reviewed, despite the fact that excellent articles on the subject abound. With the explosion of medical technology, we must discipline ourselves to employ only those parameters that materially add to the evaluation of our patients. A graphic example of this concept is poignantly illustrated in the New England Journal of Medicine’s Clinicopathologic Conference of February 11, 1982. Will the surgical second opinion have a salutory effect on cost containment? Overutilization: Albeit a worked-over problem, it is still with us. Recently in one of our hospitals a simple profile relating to 50 routine, uncomplicated cholecystectomies performed by 13 surgeons on relatively healthy patients, revealed a $1,300 differential in hospital charges, with many as high as $800 above the mean. This was chiefly due to length of hospital stay and postoperative laboratory determinations. I dare say this finding can be echoed in many hospitals across the nation and undoubtedly applies to many other other routine procedures. Findings of this kind prompted the introduction of diagnostic-related groups which serve as a mechanism by which one can prescribe a.fixed prospective fee structure for hospital-patient care reimbursement. Presently, there are approximately 385 diagnostic-related groups pegged into the program which are aggregates of patients based on age, principal and secondary diagnoses, and principal and secondary procedures. New Jersey has already implemented this program,
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and many states are considering following suit if the newly formed coalition of medicine, business, hospital, insurance, and labor is not more successful at containing costs in the very near future. We physicians must hear the clear signal issued from Washington, DC, that physicians’ fixed prospective reimbursements may be the next consideration, unless we offer viable alternatives. Since the malpractice crisis in the early 197Os, the concept of “defensive medicine” has become manifest. We all recognize its presence; however, it is difficult to identify and quantify its impact on the quality and cost of medical care. Fear of suit escalates cost by overutilization of diagnostic and therapeutic procedures that are not medically necessary. Agencies within the Department of Health and Human Services are seriously considering guidelines for certain procedures which must be performed in an ambulatory outpatient setting in order to be compensated. Already in Colorado, the Department of Social Services has mandated such a program for Medicaid patients. We should applaud the various pioneer surgicenters of Phoenix (Wallace Reed Surgicenter) and Salt Lake City. This is simply another example of why haven’t we addressed the problem and rectified it before the government agencies “forced the issue”? Can we assuage some of these vexing problems? I believe we can and must if we wish to remain one of the last bastions of individual enterprise-to say nothing about improving our image with the consumer. If we don’t, we can be assured that outside nonmedical agencies will do the shepherding. Two forces are available: first, the individual grassroots effort of each of us in our daily doctor-patient contact, and second, the concerted effort by the entire surgical sector. We must present a united front and speak as one through our organization. Since its inception, the Southwestern Surgical Congress has enjoyed a healthy and conversant relationship between “town and gown,” Each group is equally dedicated to his sphere of surgery and each is where he is because he feels more comfortable and productive there. We must strive to maintain a good balance of these two groups, as has been exhorted many times in our society. These are then, but a few challenges facing us: ones I feel confident we can measure up to.
The American Journal of Surgery