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“Who are we?” A paean to gynecologic oncology
GYNECOLOGIC
ONCOLOGY
42, 111-113
(1991)
PRESIDENTIAL ADDRESS “Who Are We?” A Paean to Gynecologic Oncology C. PAUL MORROW, M.D. Department
of Obstetrics
and Gynecology,
University
of Southern Received
California
March
Members and guests, I am grateful for your presence. Before starting my formal remarks I wish to make some prefatory acknowledgements. Accompanying me at this meeting are Jean, my wife of 27 years, and our five children. They deserve whatever honors have been bestowed upon me. Despite my long hours of work and frequent absences, they have faithfully supported me with their love, understanding, and the comfort of a peaceful home. I acknowledge to them my debt of gratitude and my love. To Peter Schwartz and the Program Committee belong all the credit for this meeting’s splendid scientific program. I deeply appreciate their tremendous effort. While the Presidency is not entirely an honorary position, as everybody knows, the greatest burden of responsibility is put upon the Secretary, the Council, the various committees, and Smith-Bucklin. To them I extend my heartfelt gratitude, especially to David Gershenson, to Rosemary Zuern and her staff, and to Rod Mortel, who almost single-handedly brought the SGO Foundation into existence. I also give thanks to you, the members, candidates, and guests, whose participation is always essential to the success of any meeting. I thank all of you. Foremost in my mind at this moment is a desire not to misuse the privilege of my office by keeping you too long or discomfiting you with a tedious speech. In pursuit of a fitting subject, I reviewed the orations of the Society’s previous Presidents and sought counsel of friends and colleagues. I have been advised to “keep within myself.” One friend says don’t try to be humerous, another advised against being philosophical, a third warned that I shouldn’t speak on political matters, and the last counsel 1 received was to not encumber an already full program with another scientific paper. These recommendations were duly weighed as I pondered various topics, realizing that in sum I had been cautioned to speak not at all. I am proud of this Society and I am proud to be your
Women’s
Hospital,
Los Angeles,
California
90033
21, 1991
President. It is, therefore, with a sense of humility and gratitude that I take this opportunity to articulate my view of our most esteemed and worthy profession. At the beginning of my career there was no expectation that such a distinction would ever befall me. My origins are rural, my talent modest, and I began my professional education with no greater ambition than to be a family doctor. I have had the good fortune, nevertheless, to be carried beyond my natural prospects by the many capable and talented people with whom I have trained and worked. Because of these individuals I now stand before you as a measure of my success in academic gynecologic oncology. It is from a background of more than 20 years as a surgeon, teacher, and writer that I address these few comments to you, the members and guests of the Society of Gynecologic Oncologists. I believe it is fair to say that I am by reputation a scholar, but today I do not wish to be academic. My prepared remarks concern two apparently dissimilar but closely related themes. The first theme is a personal tribute to this Society, the profession it represents, and, most importantly, to you, the practioners of that profession. For this purpose I have composed what might be termed a paean, a song of praise. . . To begin, we must recognize that it is a very special privilege to be a gynecologic oncologist and a member of this important Society. There are far more gynecologists who wish to be trained in the rigors of our discipline than there are programs to accept them. We are pursued by academic departments, cancer centers, clinics, hospitals, and private practice groups to take up positions which often provide a ready-made patient base, abundant material comforts, and wealth beyond the hopes of the many. Thus we must consider ourselves to be among the select in a country blessed by riches of every sort. Furthermore, the very nature of our subspecialty gives us status and prestige among our col-
All
Copyright 0 1991 rights of reproduction
0090X25X/91 $ I .SO by Academic Press, Inc. in any form reserved.
112
C. PAUL
leagues in obstetrics and gynecology, as well as in the medical community and the society at large, because we possess uncommon skills and because we have dedicated ourselves to the care of women with malignant disease. Such a formidable responsibility is and should be accompanied by respect and recognition from every social and professional stratum. Prepared by many years of hard study and intense training we perform laborious and complex surgeries; we spend countless hours counseling women and their loved ones about dangerous illnesses and the remedies thereof; we anguish with our patients over tough decisions often involving uncertain benefits and risks; we grapple with the harshness of physical and psychological pain, the threats to fertility and sexuality; and we are confronted daily by the specter of failure and death. In these and many other ways we suffer the tribulations and share the consolations of our patients and their families. We are favored indeed to be engaged in such important and personal human events. Our lives are a paradigm of devotion to humanity and medicine. And the rewards are considerable. Our patients are grateful. We receive the esteem of our colleagues. We experience the ineffable joy that comes from saving lives. It is our boundless privilege not only to attend the sick but to serve and console the terminally ill. There can be no doubt that we belong to a great and noble profession. Today, as President of this Society, I wish to recognize and applaud you and all the members of our discipline for the compassion, the courage, the ardor, and the tireless effort with which you apply your skill and knowledge for the benefit of every woman in need. We can truly say that what we do is God’s work. Having achieved such considerable stature we must constantly endeavor not just to maintain our state of competence but to advance our level of professional performance-to improve the care and the outcome of patients with gynecologic cancer. While remarkable progress has been made in the development of our subspecialty during the past two decades, there are improvements to be made, needs to be met, and, considering the size and purposes of our Society, it should take a leadership role in identifying and formulating them. That the Society needs to widen the scope of its interests and activities has become evident from the ever-increasing number of training, education, practice, and governmental issues which the members are bringing to the Council each year. It is also apparent from the almost complete absence of discourse between this Society and the many organizations, including the oncology boards, which make decisions affecting our subspecialty and our Society, that we need to institute organizational changes to facilitate the development of a productive relationship with these entities. In pursuit of this theme I wish briefly to address three areas, all relating to education, in which I think the So-
MORROW
ciety should take a more active role. First is the definition of training requirements for gynecologic oncologists. The primary responsibility for defining the training requirements in our subspecialty belongs, of course, to the ABOG. However, because Board certification is a prerequisite for membership in this Society, the Board in effect defines our membership both qualitatively and quantitatively. Thus we very clearly have a vested interest in what the requirements are, not just for fellow training, but also for the training programs. While the quality of our current programs broadly speaking is excellent, in recent years there has developed among some of our leaders a concern that our subspecialty and this Society need to incorporate a greater emphasis on laboratory investigation-a stronger emphasis on education for an academic career. While I support these concepts, I fear this focus may distract our attention from taking a careful look at our clinical/surgical training, which should have a higher priority. We must not forget who we are. Gynecologic oncologists are and must remain first and foremost surgeons; this is our most indispensable characteristic; this is our hallmark, our pith, our substance, our paramount quality. We are not radiation therapists; we are not medical oncologists; nor are we pathologists, statisticians, or research scientists. It is true that we do need skill, even expert skill and knowledge in some of these areas, and there is no doubt that years of education in an allied research field will ultimately upgrade the discipline of gynecologic oncology, but none of these things is as important as an incontestable competence in pelvic/abdominal surgery. Surgical proficiency and a deep understanding of the biology of gynecologic cancer must be recognized as the heart and soul of our specialty. If a restructuring of the educational process is to be undertaken, the first step must be to amplify the surgical training. Otherwise we run the risk that the operative scope of the gynecologic oncologist will be eroded. A diminishing concern for quality surgical training will inevitably lead to a diminished quality of surgical training. I, for one, do not want to return to the days when a gynecologic oncologist was defined by the ability to perform two operations, the radical hysterectomy and the radical vulvectomy, regardless of how successful the other aspects of my career might be. First, we must be surgeons. I believe the continued success of our subspecialty as it was envisioned by its founding fathers, as it is defined by the Board, and as it is currently practiced can only be assured by unremitting, stringent surgical training standards. These are my personal views and I hope they represent a majority view in this Society. But to repeat what I said a few moments ago, I believe the Society’s leadership should engage this and, parenthetically, all issues relating to training and certification in gynecologic oncology. The
PRESIDENTIAL
Society should gather data, develop positions on these issues, and communicate them to the Board. This Society’s opinions should be welcome to the Board as it sets its agenda and makes decisions in matters affecting our current and future members. Although the Board has yet to consult with the leadership of our Society on any issue, neither has it been asked to. It seems eminently reasonable to me that our Council should have a standing liaison with the subspecialty Board. This would be a win-win situation. A continuing dialogue with the Board will assure that this Society has input into the deliberations and actions of the Board, and the Board in its discussions will have available the collective counsel of this august Society. But we must be vigilant not only about the quality of training in gynecologic oncology. Our education must continue on a regular basis after the fellowship years to refresh and update our skills and knowledge. The SGO scientific program traditionally, however, has a paucity of papers, exhibits, posters, workshops, courses, videos, and all other educational devices on surgical topics (not to mention radiation therapy or chemotherapy) such as instrumentation, operative techniques, critical care medicine, and so on. From the perspective of a pelvic surgeon this must be considered a serious deficiency in the content of our annual meeting. Furthermore, there are altogether few continuing education courses for gynecologic oncologists available anywhere. How, I ask, are we to maintain and upgrade our knowledge and skills? How are we to keep up with medical progress as it relates to our field? I suggest that this Society offer educational workshops and postgraduate courses at its annual meeting. In addition the Society should sponsor or otherwise promote on a year-round basis continuing medical education courses on subjects pertinent to our specialty. We must take care of our own educational needs. No one will do it for us. Before I return to the theme of my opening remarks, I wish to touch on one additional area in which our Society
ADDRESS
113
and its members can contribute through education to the well-being of women. In a manner of speaking we have been keeping our light under the proverbial bushel basket. While our colleagues in gynecology and obstetrics are generally knowledgeable about the expertise of gynecologic oncologists, with the exception of the oncology specialties, we are not well known to other medical specialists, and we are all but unknown to medical-related organizations in the public sector. More important, the community of women is largely ignorant of the specialty of gynecologic oncology. Patients come to us with little or no understanding of who we are or what we do. We need to make known our special talents and services to all fields of medicine, to relevant sectors in the world of business and communications, and also to the public, especially to women. In pursuit of this and related goals your Council is instituting enabling mechanisms which include a committee that will concern itself, among other things, with public relations, information services, educational materials, and a speakers bureau to enhance the name recognition of gynecologic oncology, the understanding of gynecologic cancer, and the understanding of our specialty. In closing, let me say that I consider myself and all of us here to be not only fortunate but blessed to have this Society, which is so valuable to our specialty. We should be particularly thankful that we are participants in the renaissance, in the golden age of gynecologic oncology. The founders of this specialty and this Society must stand in awe of what they have wrought. As their benefactors, all of us should be deeply grateful to them. While some adjustments to our course may be needed, we look to the future with optimism and enthusiasm. This Society and our subspecialty will continue to flourish if we nurture it with generosity, prudence, humility, and wisdom, keeping in mind that cardinal dictum of medical practice to do always what is in the patient’s best interest. . . Gynecologic oncology, this grand adventure, this magnificent profession, will thus remain an invaluable resource and a cherished boon to our women and to our society.
ONCOLOGY
42, 111-113
(1991)
PRESIDENTIAL ADDRESS “Who Are We?” A Paean to Gynecologic Oncology C. PAUL MORROW, M.D. Department
of Obstetrics
and Gynecology,
University
of Southern Received
California
March
Members and guests, I am grateful for your presence. Before starting my formal remarks I wish to make some prefatory acknowledgements. Accompanying me at this meeting are Jean, my wife of 27 years, and our five children. They deserve whatever honors have been bestowed upon me. Despite my long hours of work and frequent absences, they have faithfully supported me with their love, understanding, and the comfort of a peaceful home. I acknowledge to them my debt of gratitude and my love. To Peter Schwartz and the Program Committee belong all the credit for this meeting’s splendid scientific program. I deeply appreciate their tremendous effort. While the Presidency is not entirely an honorary position, as everybody knows, the greatest burden of responsibility is put upon the Secretary, the Council, the various committees, and Smith-Bucklin. To them I extend my heartfelt gratitude, especially to David Gershenson, to Rosemary Zuern and her staff, and to Rod Mortel, who almost single-handedly brought the SGO Foundation into existence. I also give thanks to you, the members, candidates, and guests, whose participation is always essential to the success of any meeting. I thank all of you. Foremost in my mind at this moment is a desire not to misuse the privilege of my office by keeping you too long or discomfiting you with a tedious speech. In pursuit of a fitting subject, I reviewed the orations of the Society’s previous Presidents and sought counsel of friends and colleagues. I have been advised to “keep within myself.” One friend says don’t try to be humerous, another advised against being philosophical, a third warned that I shouldn’t speak on political matters, and the last counsel 1 received was to not encumber an already full program with another scientific paper. These recommendations were duly weighed as I pondered various topics, realizing that in sum I had been cautioned to speak not at all. I am proud of this Society and I am proud to be your
Women’s
Hospital,
Los Angeles,
California
90033
21, 1991
President. It is, therefore, with a sense of humility and gratitude that I take this opportunity to articulate my view of our most esteemed and worthy profession. At the beginning of my career there was no expectation that such a distinction would ever befall me. My origins are rural, my talent modest, and I began my professional education with no greater ambition than to be a family doctor. I have had the good fortune, nevertheless, to be carried beyond my natural prospects by the many capable and talented people with whom I have trained and worked. Because of these individuals I now stand before you as a measure of my success in academic gynecologic oncology. It is from a background of more than 20 years as a surgeon, teacher, and writer that I address these few comments to you, the members and guests of the Society of Gynecologic Oncologists. I believe it is fair to say that I am by reputation a scholar, but today I do not wish to be academic. My prepared remarks concern two apparently dissimilar but closely related themes. The first theme is a personal tribute to this Society, the profession it represents, and, most importantly, to you, the practioners of that profession. For this purpose I have composed what might be termed a paean, a song of praise. . . To begin, we must recognize that it is a very special privilege to be a gynecologic oncologist and a member of this important Society. There are far more gynecologists who wish to be trained in the rigors of our discipline than there are programs to accept them. We are pursued by academic departments, cancer centers, clinics, hospitals, and private practice groups to take up positions which often provide a ready-made patient base, abundant material comforts, and wealth beyond the hopes of the many. Thus we must consider ourselves to be among the select in a country blessed by riches of every sort. Furthermore, the very nature of our subspecialty gives us status and prestige among our col-
All
Copyright 0 1991 rights of reproduction
0090X25X/91 $ I .SO by Academic Press, Inc. in any form reserved.
112
C. PAUL
leagues in obstetrics and gynecology, as well as in the medical community and the society at large, because we possess uncommon skills and because we have dedicated ourselves to the care of women with malignant disease. Such a formidable responsibility is and should be accompanied by respect and recognition from every social and professional stratum. Prepared by many years of hard study and intense training we perform laborious and complex surgeries; we spend countless hours counseling women and their loved ones about dangerous illnesses and the remedies thereof; we anguish with our patients over tough decisions often involving uncertain benefits and risks; we grapple with the harshness of physical and psychological pain, the threats to fertility and sexuality; and we are confronted daily by the specter of failure and death. In these and many other ways we suffer the tribulations and share the consolations of our patients and their families. We are favored indeed to be engaged in such important and personal human events. Our lives are a paradigm of devotion to humanity and medicine. And the rewards are considerable. Our patients are grateful. We receive the esteem of our colleagues. We experience the ineffable joy that comes from saving lives. It is our boundless privilege not only to attend the sick but to serve and console the terminally ill. There can be no doubt that we belong to a great and noble profession. Today, as President of this Society, I wish to recognize and applaud you and all the members of our discipline for the compassion, the courage, the ardor, and the tireless effort with which you apply your skill and knowledge for the benefit of every woman in need. We can truly say that what we do is God’s work. Having achieved such considerable stature we must constantly endeavor not just to maintain our state of competence but to advance our level of professional performance-to improve the care and the outcome of patients with gynecologic cancer. While remarkable progress has been made in the development of our subspecialty during the past two decades, there are improvements to be made, needs to be met, and, considering the size and purposes of our Society, it should take a leadership role in identifying and formulating them. That the Society needs to widen the scope of its interests and activities has become evident from the ever-increasing number of training, education, practice, and governmental issues which the members are bringing to the Council each year. It is also apparent from the almost complete absence of discourse between this Society and the many organizations, including the oncology boards, which make decisions affecting our subspecialty and our Society, that we need to institute organizational changes to facilitate the development of a productive relationship with these entities. In pursuit of this theme I wish briefly to address three areas, all relating to education, in which I think the So-
MORROW
ciety should take a more active role. First is the definition of training requirements for gynecologic oncologists. The primary responsibility for defining the training requirements in our subspecialty belongs, of course, to the ABOG. However, because Board certification is a prerequisite for membership in this Society, the Board in effect defines our membership both qualitatively and quantitatively. Thus we very clearly have a vested interest in what the requirements are, not just for fellow training, but also for the training programs. While the quality of our current programs broadly speaking is excellent, in recent years there has developed among some of our leaders a concern that our subspecialty and this Society need to incorporate a greater emphasis on laboratory investigation-a stronger emphasis on education for an academic career. While I support these concepts, I fear this focus may distract our attention from taking a careful look at our clinical/surgical training, which should have a higher priority. We must not forget who we are. Gynecologic oncologists are and must remain first and foremost surgeons; this is our most indispensable characteristic; this is our hallmark, our pith, our substance, our paramount quality. We are not radiation therapists; we are not medical oncologists; nor are we pathologists, statisticians, or research scientists. It is true that we do need skill, even expert skill and knowledge in some of these areas, and there is no doubt that years of education in an allied research field will ultimately upgrade the discipline of gynecologic oncology, but none of these things is as important as an incontestable competence in pelvic/abdominal surgery. Surgical proficiency and a deep understanding of the biology of gynecologic cancer must be recognized as the heart and soul of our specialty. If a restructuring of the educational process is to be undertaken, the first step must be to amplify the surgical training. Otherwise we run the risk that the operative scope of the gynecologic oncologist will be eroded. A diminishing concern for quality surgical training will inevitably lead to a diminished quality of surgical training. I, for one, do not want to return to the days when a gynecologic oncologist was defined by the ability to perform two operations, the radical hysterectomy and the radical vulvectomy, regardless of how successful the other aspects of my career might be. First, we must be surgeons. I believe the continued success of our subspecialty as it was envisioned by its founding fathers, as it is defined by the Board, and as it is currently practiced can only be assured by unremitting, stringent surgical training standards. These are my personal views and I hope they represent a majority view in this Society. But to repeat what I said a few moments ago, I believe the Society’s leadership should engage this and, parenthetically, all issues relating to training and certification in gynecologic oncology. The
PRESIDENTIAL
Society should gather data, develop positions on these issues, and communicate them to the Board. This Society’s opinions should be welcome to the Board as it sets its agenda and makes decisions in matters affecting our current and future members. Although the Board has yet to consult with the leadership of our Society on any issue, neither has it been asked to. It seems eminently reasonable to me that our Council should have a standing liaison with the subspecialty Board. This would be a win-win situation. A continuing dialogue with the Board will assure that this Society has input into the deliberations and actions of the Board, and the Board in its discussions will have available the collective counsel of this august Society. But we must be vigilant not only about the quality of training in gynecologic oncology. Our education must continue on a regular basis after the fellowship years to refresh and update our skills and knowledge. The SGO scientific program traditionally, however, has a paucity of papers, exhibits, posters, workshops, courses, videos, and all other educational devices on surgical topics (not to mention radiation therapy or chemotherapy) such as instrumentation, operative techniques, critical care medicine, and so on. From the perspective of a pelvic surgeon this must be considered a serious deficiency in the content of our annual meeting. Furthermore, there are altogether few continuing education courses for gynecologic oncologists available anywhere. How, I ask, are we to maintain and upgrade our knowledge and skills? How are we to keep up with medical progress as it relates to our field? I suggest that this Society offer educational workshops and postgraduate courses at its annual meeting. In addition the Society should sponsor or otherwise promote on a year-round basis continuing medical education courses on subjects pertinent to our specialty. We must take care of our own educational needs. No one will do it for us. Before I return to the theme of my opening remarks, I wish to touch on one additional area in which our Society
ADDRESS
113
and its members can contribute through education to the well-being of women. In a manner of speaking we have been keeping our light under the proverbial bushel basket. While our colleagues in gynecology and obstetrics are generally knowledgeable about the expertise of gynecologic oncologists, with the exception of the oncology specialties, we are not well known to other medical specialists, and we are all but unknown to medical-related organizations in the public sector. More important, the community of women is largely ignorant of the specialty of gynecologic oncology. Patients come to us with little or no understanding of who we are or what we do. We need to make known our special talents and services to all fields of medicine, to relevant sectors in the world of business and communications, and also to the public, especially to women. In pursuit of this and related goals your Council is instituting enabling mechanisms which include a committee that will concern itself, among other things, with public relations, information services, educational materials, and a speakers bureau to enhance the name recognition of gynecologic oncology, the understanding of gynecologic cancer, and the understanding of our specialty. In closing, let me say that I consider myself and all of us here to be not only fortunate but blessed to have this Society, which is so valuable to our specialty. We should be particularly thankful that we are participants in the renaissance, in the golden age of gynecologic oncology. The founders of this specialty and this Society must stand in awe of what they have wrought. As their benefactors, all of us should be deeply grateful to them. While some adjustments to our course may be needed, we look to the future with optimism and enthusiasm. This Society and our subspecialty will continue to flourish if we nurture it with generosity, prudence, humility, and wisdom, keeping in mind that cardinal dictum of medical practice to do always what is in the patient’s best interest. . . Gynecologic oncology, this grand adventure, this magnificent profession, will thus remain an invaluable resource and a cherished boon to our women and to our society.