don't look back—something might be gaining on you

PRESIDENTIAL ADDRESS

“Don’t Look Back-Something Might Be Gaining on You”*

Bernard Langer, MD, Toronto, Cum&

I t is one of life’s great ironies that although change is one of the most important, pervasive, and inevitable

characteristics of the world in which we live, there is, in most of us, a degree of comfort with the status quo, and reluctance to either initiate change or embrace it willingly. This is of particular concern in the field of medicine in which the speed at which change takes place in our information pool is staggering, and the mechanisms for keeping current are not well developed. The motivation to keep up may also be poorly developed. What is true for individuals also holds for groups of people, and there tends to be in most organizations some degree of inertia, usu- ally based on the record of past success. “If it ain’t broke, don’t fix it” is often quoted as an argument not to make change in either structure or function of an organization, whether it be a clinical practice group, medical organization, department, or university.

One of the requirements for current presidents of the Society for Surgery of the Alimentary Tract (SSAT) is reading all of the previous presidential addresses. It is the window through which we can track the evolution of our Society. Although I see there a record of tremendous ac- complishment in terms of the stated goals of our Society, I also detect that “something might be gaining on us,” and that something is change. Not only has there been an explosion in medical information, but there has been an even more dramatic evolution (many might say a revolution) in the way medicine is practiced. In the span of my career, which almost exactly overlaps the lifespan of the SSAT, I have gone from practicing in a system of completely in- dependent, individual, competitive. private practice in a privately funded hospital, to a system of globally funded, universal health insurance in which, at least in the university setting, the vast majority of people practice within collaborative groups. In my country, government has taken over the dominant role in the funding and management of health care. and in the United States, both governments and third party insurers of various kinds are assuming an increasing role.

During this same time period. there has been tremendous change in the nature of surgical practice. The residents who graduated with me were very general surgeons, ca- pable of practicing not only the whole spectrum of gastrointestinal surgery, but also some lung surgery, breast surgery, orthopedic trauma surgery, and some head and neck, plastic, and vascular surgery. Very few of us do al1

From the Department of Surgery. University of Toronto, Toronto, Ontario, Canada.

Requests for reprints should be addressed to Bernard Langer. MD. The Toronto Hospital, General Division. 200 Elizabeth Street. EN 9.242, Toronto. Ontario, Canada M5G 2C4.

Presented at the 35th Annual Meeting of The Society for Surgery of the Alimentary Tract. New Orleans. Louisiana, May 1 h-18, I 994.

Bernard Langer, MD

of these things now, and most of us have learned since our residency to do things as surgeons that we couldn’t have dreamed of when we were residents.

In my review of previous presidential addresses, I found one early call for a critical reappraisal of the SSAT mission. Robert Zollinger’ in his Presidential Address in 1963 said; “It seems appropriate-to evaluate our position and to begin to formulate our ideas about the role of this society in the future.” I don’t know whether there was a major reexamination of the SSAT mission at that time, but given what has happened since 1963, there is good reason to take his advice now.

What I would like to do in this address is to first review some of the kinds of changes that have taken place in gastrointestinal surgery since 1960. Next I would like to refer to some of the changes that are taking place in the health care environment in which we work. I will then look at some of the concerns that these changes raise among surgeons, both in university and non-university settings, and also examine what opportunities there may be for the SSAT to play a role in dealing with these changes. And finally, I will outline for you the specific things that are being done to keep the SSAT evolving in a forward looking way.

Leroy Robert “Satchel” Paige ( 1906 1982)

2 THE AMERICAN JOURNAL OF SURGERY’” VOLUME I69 JANUARY I995

CHANGES IN THE NATURE OF GASTROINTESTINAL SURGICAL PRACTICE

I have referred to the changes that have occurred in the practice profile of general surgeons since the early 1960s. There has been an equally profound change in gastrointestinal surgical practice during that same time. When I was a resident, the operation on which general surgical trainees developed their skills was gastric resection, most often done for peptic ulcer disease. This era is long past as a result of both a decrease in the incidence of ulcer disease and the development of a range of highly effective acid-reducing med- ications. The recent discovery of the role of Helicobacter pylon‘ as a cause of persistent ulcer disease and the development of effective treatment of H pylori will be another major nail in the coffin of ulcer surgery. Gallstone disease is still the most common indication for intra-abdominal operation, but that is only because the best pharmacologic ef- forts at gallstone dissolution have so far been relatively in- effective, but that may change in the future. Common-duct stone disease is largely managed endoscopically. Gastro- esophageal reflux disease requires operation much less fre- quently than it did 20 years ago because of the improved efficacy of pharmacologic therapy.

On the other side of the ledger are a number of developments that have expanded the role of the gastrointestinal surgeon. These include technological advances in endoscopic and laparoscopic surgery; the immunologic, pharmacologic, and technical advances in transplantation; and the continuing technical improvements in areas such as liver and biliary tract surgery, pancreatic surgery, and sphincter- preserving surgery. These developments have been facili- tated by the availability of a whole range of sophisticated new diagnostic tools. The biochemical laboratory now in- cludes sophisticated immunologic and molecular tech- niques. There has been an explosion in the area of imaging, which gives us the ability to accurately visualize lesions today that could not have been imagined two decades ago. The capability of real-time three-dimensional imaging during operative procedures is not too far in the future.

These new technologic developments have also created therapeutic opportunities out of diagnostic tools that have changed the way we and others practice. These therapeutic maneuvers are all based on obtaining internal access to a patient without having to make an incision-thus over- coming the traditional distinction between surgeons and other physicians. Endoscopic instruments have allowed physicians as well as surgeons to perform numerous procedures such as removal of colonic polyps, removal of common-duct stones, and the treatment of gastrointestinal bleeding. Percutaneous puncture allows radiologists to drain intra-abdominal abscesses, obtain biopsy specimens of intra-abdominal masses, relieve biliary obstruction, and create feeding gastrostomies. Intravascular manipulation allows radiologists to dilate or obstruct vessels, create internal vascular shunts, or deliver drugs to regional areas. These developments not only change our traditional ap- proach to what we think of as “surgical diseasest” but may make US eventually redefine what a surgeon is. That this process is already going on is documented by the number of things surgeons now do that do not involve making an incision in a patient.

PRESIDENTIAL ADDREWLANGER

Another way in which both general surgery and gastrointestinal surgery has changed is through the development of areas of special interest and expertise. This process of subspecialization has led to concerns among general surgeons about the fragmentation of general surgery and among “gastrointestinal surgeons” about the fragmentation of gastrointestinal surgery. Although I am sympathetic to concerns about further erosion of general surgery, the reluctance of the SSAT to specifically recog- nize and promote evolving areas of special interest and expertise within gastrointestinal surgery has left the door open for those groups sharing a common interest to develop outside of the SSAT, for example, the formation of organizations like the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the new Liver Transplantation and Surgery section of the American Association for the Study of Liver Diseases.

Part of our problem in dealing with these issues has been the difficulty in sorting out in our minds the difference, if any, between general surgery and gastrointestinal surgery. In reviewing the numerous articles written about the future of general surgery, I have concluded that we are spending too much time trying to define it in terms of what we would like it to be, rather than what it happens to be at any point in time. Brownell Wheeler? made this point very clearly when he compared the kind of training given to general surgical residents in U.S. programs with what general surgeons actually did when they entered practice. He presented data showing that the operative experience of residents in general surgery included only 43% of operations related to the gastrointestinal tract and abdomen. He then compared this with general surgery initiates to the American College, whose operative experience was 90% gastrointestinal and abdominal surgery. It would appear from this that although we still continue to train general surgeons for a broad range of practice of which abdominal surgery is a major component, as things are evolving, abdominal surgery is becoming the dominant component of general surgical practice in real life. This led Dr. Wheeler to observe, “it is critical to distinguish between trying to preserve broad-based general surgical training and trying to preserve broad-based general surgical practice.” Much of the confusion about the importance of protecting general surgery is due to the failure to make this distinction.

We can also conclude from these data that, when we refer to gastrointestinal surgeons, we are really talking about the majority of the more than 26,000 general surgeons in the United States whose practice is mainly gastrointestinal and abdominal surgery. If the SSAT wants to promote the interests of gastrointestinal surgery generally, it must broaden its mandate considerably to include, on the one hand, that large number of general surgeons who provide the majority of specialty gastrointestinal surgical care, and on the other hand, the small number of gastrointestinal surgeons who provide a variety of tertiary services and research expertise in focused subspecialized areas.

CHANGES IN THE HEALTH CARE ENVIRONMENT

The current availability of highly sophisticated and specialized diagnostic and therapeutic capability represents

THE AMERICAN JOURNAL OF SURGERY” VOLUME 169 JANUARY 1995 3

what has been described as “the miracle of modern medicine” but which at the same time has become a major concern in every industrialized nation in the world. Modern medicine in a sense has become a victim of its own success. The overriding problem, as perceived particularly by governments. is that it costs too much. The second problem, greater in some countries than others, is that it is not widely available. And, the third problem that should be of increasing concern to physicians is that it has promised too much. The result is that patients have a higher expectation of what modern medicine can do for them than may be realistic and less tolerance for failure of a physician or the system to eliminate their complaint.

In the United States, health care cost containment is the number one item on the agenda of the current administration. The total cost of health care in the United States was more than $850 billion in 1992 and that represented almost 14% of the gross national product. There are some pro,jections that health care costs will increase to some- where between 18% and 20% of‘ the gross national prod- UCI in the early part of the 2 I st century. These are pretty scary numbers, especially ti>r politicians. There are special problems in the United States that add to the costs of health care, including the high cost of administration resulting from a variety of third party payers, each with their own administrative infrastructure and profit margins to be met. There is also the high cost of malpractice insurance that is passed on to the patient or insuring third party. The physician is increasingly becoming the focus of discontent and is increasingly seen as part of the problem. There are le- gitimate concerns among physicians. and surgeons in particular, because some of the quick fix methods have tar- geted doctors’ fees and, in some areas, have used restrictive rules to drastically alter the normal referral patterns and doctor-patient relationships. These pose a potential eco- nomic threat not only to surgeons in private community practice, but also to university-based surgeons and to their teaching and research programs.

There is also a problem in accessibility of health care. There is an increasing appreciation of population health as a measure of the success of a country’s health care system. Even if it is true that the best health care in the world is provided in the linited States, there are large numbers of people to whom it is not available. The net results are population measures of health that are lower than those in other countries that spend much less overall on health care.

Finally, there is a much greater interest on the part of governments, third party payers, hospital administrators. and now consumer groups in evaluating the quality and appropriateness of care. In the past. it was believed to be largely the responsibility of the profession to audit their results, for their own USC. For a variety of reasons, most of them good, it has now become necessary for the profession to more explicitly demonstrate to others the effectiveness of the health care it is delivering, as well as the cost effectiveness. It has also become necessary for physi- cianh to broaden their concept of medical care from simply diagnosing and treating disease in the individual patient. to becoming involved in broader issues of population health. including developing strategies for disease preven- tion and health promotion.

OPPORTUNITES AND CHALLENGES FOR THE SSAT

What does all this have to do with the SSAT? The objectives of the Society as stated in the by-laws are: “to stimulate, foster, and provide surgical leadership in the art and science of patient care; teach and research the diseases and functions of the alimentary tract; provide a forum for the presentation of such knowledge; and encourage training opportunities, funding and scientific publications sup- porting the foregoing activities.” The SSAT has fulfilled its objectives in the past by organizing this annual scientific meeting, presenting an annual postgraduate course, fostering research training, organizing with Ross Laboratories a conference for research trainees, and providing faculty development awards for young academic gastrointestinal surgeons. It has also participated in a pe- ripheral way with other organizations in a number of con- sulting and advisory bodies. It has however continued to be a relatively small organization, with less than 1,000 active members, selected almost entirely from university surgical faculty. Although it has fulfilled its defined mission in education and research very well, it has not become involved in a proactive way in adapting to, or attempting to influence, the various changes that are taking place.

In recent years, some of our Presidents have encouraged us to reassess our mission and to consider making changes in our Society to address some of the issues I have outlined. Ron Tompkins3 in 1987 pointed out the deficiencies in many general surgery programs in the area of complex gastrointestinal surgery. He suggested that the SSAT become more proactive in working with program directors and other administrators to strengthen gastrointestinal surgery training for general surgical residents. In 199 I. Bill Silen” proposed that the SSAT assume a larger role in continuing education and reach out to a larger audience, not only of surgeons, but to all those interested in gastrointestinal diseases. He also suggested expansion of our membership to gain access to that wider constituency. III 1992. John Cameron’ carried the analysis of specialized gastrointestinal surgical training further and proposed that the SSAT develop structured advanced training programs for individuals who wish to provide tertiary gastrointestinal surgical care. Last year, Keith Kelly6 expanded on these themes and proposed that the SSAT play a larger role in more clearly defining the field of gastrointestinal surgery and in providing more leadership and cohesion, including broadening its effort in publications.

With this background. a major effort has been made this past year to reassess the goals and objectives of the SSAT, particularly with regard to its responsibilities in education, research, health care standards, and health policy, and also its relationship to the large number of general surgeons in this country who practice gastrointestinal surgery. The SSAT membership was consulted by means of a questionnaire, and a retreat was held in mid April of this year to develop pro- posals for the Board of Trustees and for the membership.

I will first briefly provide you with some of the data from that questionnaire. At the outset, I have to point out that there were only 314 respondents out of a membership of I,2 15, of whom 8 16 are active members. This information, therefore. represents the views of those members in-

‘1. THE AMERICAN JOURNAL OF SURGERY’ VOLI~ME 169 JANUARY 1999

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TABLE I Society for Surgery of the Alimentary Tract

Membership (314 Responses)

Age 30-39 40-49 50-59 60-69 70c

Sex F M

18 104 100 68 23

11 300

TABLE II Location of Practice

Non-university practice 70 University practice 235 Rank

Lecturer 4 Assistant professor 17 Assocrate professor 70 Professor 170

TABLE Ill Membership in Other Organizations

ACS 280 AGA 105 CICD 128 ASGE 37 SAGES 98 AASLD 23 ASCRS 37

ACS = Amencan College of Surgeons; CICD = Collegium lnternationale Chlrurgrae Digestivae; SAGES = Socrety of Amencan Gastrorntestrnal Endoscopic Surgeons; ASCRS = Amerrcan Socrety of Colon and Rectal Surgeons; AGA = American Gastoenterologrcal Association ASGE = American Socrety for Gastrorntestinal Endoscopy; AASLD = Amencan Assoclatron for the Study of Liver Diseases.

terested enough to return the questionnaire. I want to take this opportunity to thank those of you who did so and who provided many insightful, and sometimes entertaining ad- ditional comments for me.

The demographic data shown (Table I) suggest that we are a middle-aged to older. predominantly male organization with five times as many members over age 60 years than under age 40 years. Almost one third of our total membership are senior members. The vast majority of our respondents practice in a university or university-affiliated hospital, and a surprisingly large majority have attained the rank of full professor (Table II). There was substantial membership as well in other organizations. Almost all North American SSAT members belong to the American College of Surgeons since it is a membership criterion. There is also substantial representation in international organizations like Cotlegium Internationale Chirurgiae Digestivae (CICD), as well as the major North American organizations with an interest in digestive diseases (Table III).

The two important issues that we particularly sought opin- ions on concern the mission of the SSAT and. closely related to that, our membership policies. On the question of mission, the majority of respondents believed that the ha-

PRESIDENTIAL ADDREWLANGER

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TABLE IV Society for Surgery of the Alimentary Tract Mission

Yes No

Keep objectives unchanged 212 31

Increase continuing education 221 44

Increase role in health policy 147 105

Become major organization that speaks for gastrointestrnal surgery 122 140

TABLE V Formal Advanced Training Programs in

Complex Gastrointestinal Surgery

There IS a need 177 -provide tertiary care 158 -prepare for academic career 121

There IS no need 108 -restructure general surgery training 108 -local instrtutional fellowships 44 -preceptorships/on the job 33

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TABLE VI Society for Surgery of the Alimentary Tract

Sponsored Journal Yes No Undecided

Support SSAT journal 93 159 61 Submit papers to SSAT journal 166 44 92

sic objectives of the SSAT. which I outlined previously, do not need to be changed (Table IV). There was, however, also a majority view that the rote played by the Society in continuing education should be expanded and that the SSAT should increase its profile in the area of health policy issues. There were also a substantial number who believed that the SSAT should become a major organization speaking for gastrointestinal surgeons, but they were not a majority. With regard to criteria for membership in the SSAT. a slight majority wanted them to remain unchanged. Those respondents who favored opening up the membership often linked this in their comments to the expansion of the roles they perceive for the SSAT in the future.

Specific questions were asked about the need for formal advanced training programs in complex gastrointestinal surgery (Table V). A ma.jority believed that there was a need both to provide exemplary tertiary care and also to prepare individuals for an academic career. Those respondents who believed that there was no need for such programs thought that the quality of training in gastrointestinal surgery could be improved by restructuring existing general surgery programs, and that the informal mechanisms currently in place, as indicated, are sufficient to provide tertiary and quaternary specialists.

The strongest views were expressed in responses concerning the possible SSAT-owned journal (Table VI). The majority of respondents believed that there were already too many journals, and only one third wanted to see the SSAT develop another enc. Of interest, the majority of members would submit papers to an SSAT journal if one were developed.

THE AMERICAN JOURNAL OF SLJRGERY” VOLUME 169 JANUARY I905 5

PRESIDENTIAL ADDRESSKANGER

These issues were addressed at a retreat of the Board of Trustees and three working groups of the Board held in mid April. There was a strong consensus at that meeting that it was timely to significantly expand the functions of the SSAT in the areas of education, research, quality of care, and public policy. In coming to the conclusion that the SSAT should play a much larger role in representing the interests of gastrointestinal surgery and gastrointestinal surgeons in general, it became clear that to do this the SSAT needed to expand its membership so that it could truly represent those practitioners who actually deliver the gastrointestinal surgical care. Such an expanded membership would be brought about not only by a change in the criteria for membership, but also by offering a new cate- gory of trainee membership to general surgical residents and gastrointestinal surgical fellows. The result would be a major change in this organization from an elite group of surgeons practicing mainly in university hospitals to a broadly based organization representing the whole spectrum of surgeons whose major interest is gastrointestinal and abdominal diseases.

The retreat resulted in a series of specific recommendations that were presented to the Board of Trustees and were approved by them. These recommendations include the development of changes in the constitution and by-laws, and the setting up of several new committees and redefining the terms of reference of some old committees in order to implement our new vision.

At this point, 1 would like to provide you with a little more detail regarding our discussions, both at the retreat and at the Board Meeting concerning the current role of the SSAT, the areas in which change is thought to be de- sirable, and the steps needed to be taken to achieve a new set of goals and objectives.

Education The first area of interest is the training of gastrointesti-

nal surgeons. The SSAT Board has previously considered a proposal to create a new specialty of gastrointestinal surgery, with its own accreditation and examination system, and concluded that it was undesirable. There is, however, much concern about the dilution of training in complex gastrointestinal surgery at the senior general surgery resident level because of the requirement of full general surgical training by other subspecialties, who will never use that training in their practice. A re-thinking of the training requirements may be required in general surgery as well as in other specialties based on general surgery. The question that remains concerns the special training that may be required to prepare an individual either for a career as an academic gastrointestinal surgeon, or as an exemplary tertiary care specialist in one or more specific areas within gastrointestinal surgery, There is general agreement that the vast majority of general surgical training programs cannot provide such preparation, The SSAT

will continue to study this problem, and a new Education Committee will be appointed, and as its first task it will document what advanced training programs currently ex- ist, both of the fellowship type. and the short course, hands- on type of program for specific training in new technological procedures. The question of SSAT approval of

specific programs remains open, although my personal view is that our Society should become involved in setting standards for such training programs, and eventually accrediting them.

Continuing Education. There is a much larger role that the SSAT can play in continuing education. Currently it is confined to those individuals who attend our meeting and course at Digestive Disease Week. If our membership ex- pands, we will reach a larger audience through our meeting and course. It has been proposed that an SSAT journal focused on gastrointestinal disease might also be an important vehicle for continuing education. As you saw from the survey information, there was not a lot of support for embarking on a new journal at the present time. As our mission and composition change, the arguments for a journal may become more compelling, and without pre- judging the issue, the Board is creating another committee to look in more detail at the current track record of other surgical journals with overlapping interests, and to do a more detailed feasibility study including costs, potential readership, potential partnerships, and usefulness of a journal as a communication and continuing education vehicle for an expanded membership.

Public Education. Finally, there is the issue of public education: By this I mean not only the education of the man or woman in the street, but the education of those people who are increasingly becoming important in making the decisions in the health care system that will pro- foundly affect our lives. These include the politicians and a whole variety of major and minor bureaucrats in federal, state, and municipal governments; health insurance com- panies: health care advocate groups; etc. Any of you who have had dealings with people in ministries of health or third party payer organizations will be aware of how deep the level of ignorance can be about how medical care is delivered, and how much they need and, surprisingly, how much some of them want input from physicians in order to better understand how to do their jobs. It is important that an organization like the SSAT play a visible and prominent role in both these areas of public education.

Research It has always been among our objectives to promote re-

search in gastrointestinal diseases. We all know, however, that it is individuals that do research-not organizations. Organizations can, however, play an important role in the promotion of research, and the SSAT has a major interest in fostering research, whether it be in the basic biologic mechanisms of disease, or in clinical studies involving individual patients or patient populations. In order to be most effective, surgeons must be involved in all of these aspects of research, since we provide the link that relates to the work of the full-time molecular geneticist in the laboratory to the clinical problem in the individual patient in your office. It is interesting that there are many more surgical trainees involved in research at the basic science level than in the clinical studies arena, even though there are hun- dreds of important questions that need to be answered in clinical surgical practice. The field of clinical epidemiology has not yet received the respect that it should as a scientific discipline, which is essentia! to providing the very

6 THE AMERlCAN JOURNAL OF SURGERY” VOLUME 169 JANUARY 199.5

basis on which we make our every-day practice decisions. One of the world leaders in this field is Dr. David Sackett, who will be giving the Presidential Guest Oration on the subject of “Clinical epidemiology-a basic science for clinical surgery.” Dr. Sackett has developed a training program at McMaster University that is producing a generation of people who, along with their colleagues trained by Alvan Feinstin, Walter Spitzer, and others, has the potential to have a greater effect on the way we make decisions in every-day medical practice than our molecular biology researchers. And they will do that by converting. as much as is possible. our medical care from being empirical and experience-based to being evidence-based.

An increased role in the research area for the SSAT could also include an expansion of funding of both fellowship and career development award programs through an increase in our membership, along with participation from industry. In addition, the expertise within our Society could be used to develop focused consensus conferences on areas of evolving technology. Finally, even though our organization as such cannot do research, it could identify specific problems worthy of clinical study and encourage the development of collaborative clinical trials by bringing together groups of people in the hope of initiating such studies. The Research Committee of the SSAT has been asked to reexamine its current functions and to make recommendations regarding an expansion of its role in these areas.

Standards of Care Although most of the activity in terms of health care re-

form has been driven by the need for cost containment, there is an increasing public interest in standards of care. This is, in part, due to the desire for cost effectiveness, but also results from an increased sophistication on the part of the public and health care planners, not to mention com- panies heavily involved in medical liability insurance. The tnedical profession, more than any other group, and for longer than anyone else, has been concerned with quality of care and outcomes measurement. The emphasis in the past was almost entirely based on academic interest and took place mainly in teaching hospitals under the rubric of “research.” It is clear now that physicians in general are having to become involved in quality assurance programs, and hospital-based physicians, especially surgeons, will become very familiar with ongoing outcomes assessment activities. An essential component of quality assurance is the establishment of agreed-upon standards of care, or practice guidelines. This is a highly charged issue, and not only are there major differences of opinion between individuals in the profession and outside the profession, but among physicians themselves.

The development of practice guidelines is currently going on and will increase in the future. As a principle. these standards should be set by the profession with the welfare of our patients as our primary consideration. It will be increasingly important for physicians and physician organizations to emphasize the use of practice guidelines as a tool to itnprove patient care, rather than simply as a cost containment measure. Ideally, these two objectives should be complementary. The SSAT should play a much larger role in dealing with these issues of standards of care and

PRESIDENTIAL ADDRESSLANGER ___-

clinical practice guidelines than it has in the past. For this purpose, its Patient Care Committee is being reactivated and will be asked to redefine its mandate to include a specific role in this area.

Public Policy Issues There are a number of other issues that have been in-

cluded under “health policy” that are currently largely in the hands of a new generation of professionals going by a variety of titles, including “health economists,” “health planners,” “managed care specialists,” and so forth. It is important for physicians and physician organizations to develop expertise in the health policy area so that they can participate in discussions regarding things like medical manpower planning, definition of physician roles in health care delivery, regionalization of health care, and reim- bursement policies. The American College of Surgeons has made a major effort in dealing with these issues, vis- a-vis government and other organizations. Our Society does not wish to compete with or overlap the initiatives of the American College of Surgeons; however, we may be able to work with the American College of Surgeons, particularly by providing expertise in the area of gastrointestinal surgery.

As you can see, the recommendations coming from our retreat have set the stage for a major change in the orien- tation and function of the SSAT. It has the potential to become the major voice for gastrointestinal surgeons, greatly enlarging its membership, and through that its scope and strength, without in any way sacrificing the academic ex- cellence that has characterized the Society in the past. This process of change will require a lot of work by many people, and it is hoped that during this evolutionary phase there will be more participation in the activities of the Organization by its members, particularly by its younger members. We very much want input from our constituency and hope that many of you will make your talents available to work for the Society in the coming years. This will be a very exciting time for SSAT, and I consider myself very fortunate to have been involved at this point in its his- tory. I think that if Bob Zollinger had sat in on the retreat and at our last Board Meeting he would have been de- lighted with what SSAT is doing at this time.

ACKNOWLEDGMENT I would first like to pay tribute to the three people who

most influenced my career at the professional level. Dr. Fred Kergin was Chairman of the Department of Surgery at the University of Toronto when I was a resident. He was an outstanding role model as a clinician and teacher. He was also a man who was feared both by his residents and staff because of the tremendously high standards he set for patient care. He lived by those standards himself and not only demonstrated superb clinical skills, but hon- esty and integrity.

Dr. Francis Moore was my supervisor for a too-brief period of 6 months during which I worked in his laboratory at the end of my clinical training. He opened my eyes to the importance and excitement of basic research in academic surgical practice, and the possibility of combining a career as both a clinician and scientist. That experience led

THE AMERICAN JOURNAL OF SURGERY’* VOLUME 169 JANUARY 1995 7

PRESIDENTIAL ADDRESS&ANGER

me to the conviction that research was not only an essential component of an academic department of surgery, but essential to the development and progress of surgery itself.

Malcolm Brown was an internist whom I came to know when he was President of the Medical Research Council of Canada and I was a member of Council. He was an outstanding physician, investigator, and teacher, but in the middle of his career assumed the role of a full-time ad- ministrator, something I found hard to understand. He taught me the importance of people with knowledge and talent in the traditional areas of medicine taking on responsibilities in leadership and policy making roles. In his case it was national health research policy, but the same kind of people are now needed to participate in health policy planning generally.

I also want to express my thanks to those members of our Society who have been so helpful and supportive during this year-David Nahrwold, Keith Kelly, and Larry Way who prepared the position paper for our Retreat, and our secretary, John Ranson, who provided good advice and

the longitudinal perspective of the organization that a l- year president can never have.

I also want to acknowledge my appreciation to my wife and best friend, Ryna, who not only has provided me with encouragement and support over many years, but was a major help to me and the Society in producing and analyzing the survey this past year. It has been a great honor to serve as your President and I thank all of you for this opportunity.

REFERENCES 1. Zollinger RM. Justifying our existence. Am J Surg. 1964:107: 233-238. 2. Wheeler HB. Myth and reality in general surgery. Bull Am Cd Surg. 1993;78:21-27, 42. 3. Tompkins RK. Gut reactions. Am J Surg. 1988:155:2-5. 4. Silen W. Where have the general surgeons (doctors) gone’? Am J Surg. 1992:163:2-d. 5. Cameron JL. Is fellowship training in alimentary tract surgery necessary’! Am J Surg 1993; 165:2-8. 6. Kelly KA. New directions in gastrointestinal surgery. Am J Surg. 1994;167:2-7.

8 THE AMERICAN JOURNAL OF SURGERY” VOLUME I69 JANUARY I995

don't look back—something might be gaining on you

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