A M E R I C A N C O L L E G E O F S U R G E O N S

Vmlume 39 JANUARY FmBlj&&YL 1954 N u m k 1 . '

The Responsibility of a ~erituge* Fred W. RPnkin, M.D., ~.a.c.s.,+exington, Kcncuclry

FOUR DECADES AGO, on 5 May 19x3, there met in the mpid of our nation a group of s-ns who "pmcntod rhc cIdw swtesmcn of our guild in the Uni~ed States and the Dominion of Canada. This ms m e m 1 date for it marked the birth ofthe Amerim College of Surgeons. Thae men m g -

C d nized that ccrcain change in medial aduation and , hospitalization p d - , and ccrtain trmh in . surgi~p1 practice, demanded a dodic~tion of sur-

geons to tht traditions of the p t , a fomd-look- - v iog ptogtam for the future, and a rc-cmphads of pli the prhdples for which the medical profession in

, its ultimate strumre has always stood. It was for

msons that this oqmimri~n was projected.

11 The Founders ofthe College set up two quirt- mwm fbr Fdmhip . The first was professional ability. The second, which was equaIly imp- was the highebt ethical and moraI ~~. These men., hawever, were d m m well as idcdks. T h y were d e t d e d to admit to Fehmhip only men who were primarily spbciatigff in surgery. But they m q p k d - p u must remember that t h ~ w a s ~ o y e a r s ~ t h a t ~ F h a r a m r ~ n d s k of the aommunitp in which the candidate was p d d n g must, ofaecessity, be taken into consid- eration. As time has passed, the original necessity for Wbiliy has dimifii&ed, and we are now very claee to thc wigid objective.

THE mCS OF SURGICAL PRACTICE

Considerations of moral and e th id conduct must haw weighed heavily upon the ~ U I C B of the Foundem of rhc College. Eleven yaxs after its founding, when the Congms -bled in New

*FeIlaw&p A d d m b Dr. RanhiD as the i n c ( ] m i m ~ d c n t d r h c ~ ~ u f S u r g e o m , at the Charl- Chiago, Oaobtr 9,1953.

M d n , recalled in his annual report the dxamatic moment at the organization meeting whtn "the mpdcrcd dean of sutgcty in b k Indiana," Dr. Miles F. Poricr, rosc in hi plaoe and pleaded for "a declaration against the division of*, the pay- ing of commissions for surgid wark, the buying and selling of ptients." Dr. PoWs challenge, Dr. Martin continued, was aacptcd whh mthu- siasm and a dedamtim apinst thc division of fees, a p d c e in which dl the wils Dr. Porter had named were tmboditd, forthwith k a m e one of the ardinal principles of the American College of Surgeons. The dedmtion was immediately im- pkmmcd by the Board of Regem, and mo fur- thcr dcclmtions a t what Dr. Martin rightly d l c d "this abominabl practice" wcm prepared. The h t was the so-all "4, battle-ax pledgt, which dl Fellows have ever since signed, as part af the ritual of their admission to the College. The sec- ond was the Fellowship Pled= a m d v e declaration a g h t unworthy transaetiolrs and a stattmtnt of the 0 t h amenhies of surgical pradce and thc obliptim of Fellomhip.

I think it im-t that in this FeflowsUp ad- dress I should rtcall thee m t s to you who have just beea accepted as Fellows of chis ColIege. The ceremony which admittcd you plncts upon you terrain iespnsibititits. You must iive up to thaa obligations. It dm placca upon the College the respnsiMiy of voucbiag for you in the epes of the d d . It stared and implied that this orpnim- tion, after due prww of investigation and -- ination, has determid that you art both m- perent and worthy.

It is o melancholy, but undeniable, fact t since the end af World War I, and men more dncc

the end of World War 11, the d fiber of this nation has Iost much of im sucngth. Pcrhp it wan incvimble in this torn d 4 W ~ M C idmlogies dash and the very &mncc ofnations is at mkt, that the higher values should have k c m ~ e , and should remain, darkly clouded. Yet we cannot @tthccardinalvirtu#ldhon~andintcgri- y, and the stoutnum ofdmacter to which we give the old-fashioned name of uprightness, to lx pushad into the backgmmd and thcre to rtmain dormant. Thac are still the spiritual valum which man should live by, T b things apply to us surgeom. There arc

m e in our midst who do not recognize their obli- gations or who, mgnizing them, lack the courage to live by them. They fall into rhe twin pitfalls of avarice and ill-gotten gains. They persuade them- selves that they art justified in what they are doing. The philonophem would d l rheir reasoning logi- calizcd prag mtism.

It is regrettable that for the most prrt the men who are so conducting themselves are of the younger, postwar g-tion. But that d~ not relieve us who are older in the profasion of blamc far what is happening. We how that these atti- tudcs exist. We am aware of surgical p r a m which violate pmfasiod principles and the prin- ciples of simple morality. Yet thm is ample evi- dence that ctrmiD scgaum oftbc profwon either blindly ignore what is h a p p h g , or mntcnd that it is not happening in their own communities, or argue chat it is ofMe eomequmc~ in the o m surgjcat picture,

Let us fie the facts W y and honestly. Let usadmitthatrhemanzmainourprofash- forhmately th& number is small-who praciiot division of fees, who do ghost surgtrg, who per- form u n m c w q qnmtioas, and who charge exorbitant fges for thcir semi=. Their number, a s I s a y , i s s m a I l , b u t e v e n o n t ~ o r ~ directly and unfavorably u p ua all.

What is our responsibility in the matter? It is, Isubmit , tomkeverp&orttotad~prac ti-. All of us arc awarr: of thcm, m n thaw of us wbodonotopenlyadmitthattheyexist. Butto prove them is of such m e acuity that few d us are willing to make the effort and endure the unphanmess that &e productioo of rht proof roqui-. Let me remind yw of someding rhat Linaoln is s u p p e d to have said, and might well

have said: to a c q t by silence what they should pmm make cowards of men.

The p m a k whi& I h e listed h m been con- demned by the American Medid Assodatian, by numerous state organizations, by the m a t impor- tant of our surgirral orgmkitiofts, and by all of us, Ithk,iaourhtarff. Iprefkrto believetfiatthe condemnstion has ken made in all seriousness and sinmity, for these practica bring odium upon us all. It is hard to see> thcrcfore, why when a surgeon condemns them in public addmses or in press ia- tewiews, he h d s himself the one to be censllred Can it k that the condemnation of evil pncticw i i no morc than lip sewice, no mwe than a owcession to expediency? Within the past year, as I tbhk most of you know, ammprs have a d y km made in certain medical organizations to discipline Regents of &is CoUegc who simply told the mth about thee invidious praetic~ in press confer- ences. These attempts did not succeed. I doubt that such &om will ever s d . But that b ispluc should haw been dsed at all lea= one won- dering-is thc explaaation that the wicked flee when no man pursue&?

Letmcnawrurntoothtrmaftm. Oaeofthm is the development of spdaliatim and its impli- cations. SiDccthcturnofthc~thishasbecn one of the outstanding c h a w in madid practice, particularly in the field of surgery. As this dewflop- merit W e more and morc midat, the leadm dthc p h i o n , who were c o d with making media pmcticc morc s&m& and with the p- cfvation of h i g h tthical standards, amc more and marc to Pcccntute the hpmaucc d this PI0m-m In 1886, something ovtr a q m af a mnuy

befwe the M t g e of Su%#ws came into existence, SamuclP. Gmss,inhisinaugurrrladdrusas~ idem of the American Surgical Man, said that he Mt safe in saying that there was not then in thc w M couatrg a medical man who dtvotd himaclf cxclusivcly to rhe praaia of surgcry. Amriuu~ medid mcn, he cpnthd, were general pradtioncrs who owercd thc entire field of madi- dnc, surguy and obsrctric3. This situation has, of ~ , b c c n c o m p k l y ~ f o r a m z ~ l b c r o f reasom. The h t is the elevation of standards of graduate instruction in d e m i c centers. The second is the -tion of surgeas by commit- tewr drhtir -, as repmerited by the Amerim Bclard of and-the hdkn College of I.

h3 Suqmar. ThE third is rhe C which has come aboit in the adminisuation of hospitals, a change which was begun and has been continued in largc pit by the d o r m of this College.

I do not propogc to discuss wnighr tht que$tim of s p e d b h io its relationship to the p r a d a of medicine. I am, of course, a& of the eom- plaints that we have too many s p d a k s , and that the specialist taka tm narrow a view of his own field.- 1 am c o n e d , however, that we do not haw too many adequately trained s ~ t s , and I am qualiy m n v i n d that aurgcry is still too k- quently being done by nam oftoo little training and &perim. This problem will not be solved by attcmpts to ddhmte the boundaries betwcca minor and major surgery. Minor surgery, when done by an did hand, is major surgery. Let me assure you, if you have not already lamad, that whcnywarcyoutsc l f~epa~eat ,aLl~a lpra- cedum, single or multiple, simple or formidable, are very personal errperiencts. Any s u r p n who bas btcn nsinisterad to by bis Mow surpm, howcvcr sutwtssfuUyy knows that, and understands, too, what P a m m mant when he said that when his own time camc, hc would not wish to be oper- ated an by a surgeon who "did not care a whole lot."

The old-time pncral practitioner has in large masure passed with the Fhanging times. Perhap that was M t a b l t , but it is sti l l to be deplored. The cornerstone of medical practice should still be this tgpc of physician, who rtpmcntcd, at his bat, integrity, moral character, adfksnm, willingness to - w i h or without remumath, aed wirhout mnsidcrption of his o m time and mdim, because he was dediated to the h o e of his fdlow men.

There have arisen in recent ccmh groups fostered by h h medical and surgical dcmetits within the pmmt body of Ammian medicine, as well as by & surgical cwttmpmries, who haw a t h a n d the the& that a physician with a diplama h m a recognized medical school, supplc- mentcd by a pear's internship, is apable of &ng for 85 per ceat ofthe ailmenm to which man is sub ject, irIduding grave surgical illness. To ad- such a is tither to lx incredibly naive m to assume that the average layman is complaely la&- ing in knowledge of what ~ t e - s o u n d sur- gical p~cricc. To atttmpt to suppan rhis argu- ment by an e o n of yearning for the retura of the old-fashioned general practitioner, Is to as- sume the attitude of the o d c h toward change and -

L p w in di-s, d and treatment, and

t o d c n y t h a t s c k n c c h a s ~ ~ r h a n s t a n d s t i l l oetr rhc k t half d thi ocntury.

Thnt arthy philosopher, rhe late Dr. Aahu Hcdcr, said in his Hmss and B w Mar that the time was mpidly lrassing when a physician m u l d ~ u p s o m e f i a t m o r a i a g a n d ~ t h a t he was a surgeon, The late Dr. C Jeff Miller, a former president of this College and a man of s i n g u h gentleness and M y , d to a, with a good deal of m, &our "a-appointed s w - ists." Sir William Osier said that no morc danger- ous membtrs of thc p e w exist than those bm intD it, so to s p k , as specialists.

All of thc im-t medical sodedts of the county m-operated in setting up xhc hmh in surgery and the surgical s w t i e s which put an end to that situation. A dehite p g m n now exists for tbe training of s u r g m m by the &- ation of all available hospital and aching fa&- ti-. Pool's* lamentation& his pddtntial add- bcforc the Amerian Surgid Aszdatim in 1936, that the weakest link in the chain ofmadical educa- tion is postgraduate surgery is no 1-r me. Thm are still insuKuent opportunities for the uaiaing ofall physicians who wish to become sur- geons, but the program of graduate instruction has k n enormously in-. Oae of the advance is thc utilitntion of hospimls of 300 bcds and up ward lomcd in thc smaller &cities. These hapitala have no direct maacction wi& medid sdmh, but if they arc Ioared nat roo far distant from teaching ccntm, and if they are properly d u c t - ed, ~ s n contribute a most positmt and useful clement in ptgmduate teaching.

HOSPITAL ST-TION The sbdadkd , accredited ~~ is a p W

in the edifice of modern mr-, and a most ira- portant one. It has two fun&oh. The first is its teachiag Mw. The second is the pmction of the patient. This means the cnforcrment of stand- ards determined by the medical profession and based ody upon prof~siaaaI abiliG and moral in- tegrity. In plain words, this m m that staffprivi- leges should l>e limited exdusively to @iftcd surgtons. It mans d m only q d h d surgeons, or surgmns who uro* under su&sion in the prw- ess of quaUdon, should be @fled optrating

T h e Making of a Surgeon," Tram -4th A-rn S @ A W I 1936954: 1-11

J h # n o ~ a b o r r t ~ ~ . T h i s i s a p r q m m ~ i s a e t e h e r ~ t o s e t u p n o r m y m a d m j n i s m h b ~ m d w i t h t d h g i m ~ d l h o t p r d d e d w & iadepeoQtnt - s u p p a - ==Y h o q i m l b a s a ~ ~ i a ~ m o t c e r . It must insist t&t pmfmkd armbtwxt and naoraldMMcrM-*-d t h t h o s p i d ~

~ i n t h e ~ ~ t i o t l ~ h m k n s p m c u k i n ~ ~ d s l o w i n o t h ~ A g m t m p ~ w m m k c n w h w t h t J& - . . m W t d m of H q i t d s wasmcmlywap,rmd#rhea~aftheApl- e r i c a n ~ d ~ t h t ~ M o d i d Associa&> the h u i c p f l College oh Phpgidplkp, the Amaim Hospital Mth, and the Csaa- dian M a l i d -on. Tbis pmgmm a m m M. l t w i l l ~ b a ~ l e a ~ s a l ~ ~ u p m r t h e w h d e ~ p i ~ . IthuIdimplwtMs- pital d u . It should el- phiad per- f4mmcc F i d y , i t ~ m o d K y a a d ~ o t l r p a r b l i c ~ w h i c h ~ b ~ m s q in need of refomretion and tcvitabtion.

Andnow,onrragnh,ktmeedkmplfdi- ~ y t o t b o s e d p w f a o a f t & y ~ t t c d t ~ Fellowship in the -. b t me Oger pou m c a & P i c e w h i c h , a s a ~ p d a e n t o f H a t - W r d r n ~ ~ ~ n ; m i l s r ~ t o a g m d ~ ~ t i n g ~ i s s t i U ~ , h t h e ~

although it has ftsqtaendy been itlmssddum,ifever,lxm&uplw.

Yours L a mble heritage. You arc, a HBggerd ~ i n i r i s ~ ~ d r s s t o t b i s C o Z H e g e , ' " t h e ~ d i s + l e g o f d t h e ~ ~ w h o h a v t g lbrh i he.,'' Yaw b-und in ssragery is uwmtdly in charma, though tin& witbar- ' method of d n g . The corn- b i m b lms - a generation whose duy it ism- t h c a a d i t i o r t s d t h e ~ w o r ~ d B they dated befm two g k k l mn,

Y o u ~ w h a d w q i n g p p w l d . T h t ~ a ~ i s -the aftemmi of the gob age of s m . Fmsc- t i o n r a t h e ~ t h a n ~ ~ ~ ~ i n mrgical i n f m . The ammk 8- is bdng ~ b y t h e ~ ~ d ~ . lbrmm a d ~ i a ~ c e l p ~ u r e s h a v e b e m ~ i i '-'-qwpW? d h -

Dr. P*sd w. w-n, L&tsgton

nostic prwedura, preoperative and postoperative managancnt, and hospital programs. In all of these advanc~s the surgeom of the Unitad Seam have played an importmt rok. If you art not dmdy familiar with it, k me cornmead TO you Evam Graham's s&My ptesiddal address to the CoUegc in r 941. In it k related the dtwlop- men& of modern surgey up to tht time--I need not remind you how many there have been sine that dmc--and pointed out that '% Eoret of ~ m c c p l the ~lurgical world will surely look to Amcria for leadtrship." Ameriea~ surgeons, hc went on, must be prepared to assume that hder- ship. Tbe def&t of Nazism a d the correlated end of the dqgmLion of medial pramice fox whicb that wicked doctrine as responsible has pMrmiaed IU to preserve our surgid heritage, though there has k n a hiatus of a d e d e or mrc. The stand- ards which we have set* and which must be pre- served at all costs, demand forceful, forward-look- ing, even aggressive umgkd d o n .

It is an unfortunate paradox, as hul Hawlcy said, that mvu before haw thert been so many competeat young surgeons as arc king trainad mhv. and nwer, annmndv. so many who a q

pmui~t. 'I'hqhavt~minedinsurgidcrhics u n d ~ ~ e r s w h o , a l m D s t w i t b D u t u ~ o n , a r c men of principle as well rn of ability. But w h *mtcrpictiaafter:thtit~aaining, thy often enm~nm dillidria in the 1- in w h i c h t h e p h a v e c h o s e n t o ~ ~ m h u s e ofthe loose praaices to which they are ex- psed by theit c d h p e s who are olrtadg es- mblishtd.

I gram that this unhappy sihladw exisc~. Nonc- thek, I think it ~ c i o u s to argue rhat a young slrrgconwhOis~bpthcAmericaflBaQtdof Surgery and who holds Fellomhip in the Amerrium Cdcgc of Surgmns annot survive economidly h a small ~ t y i f h t o ~ theethicsof his pmf&m, if he mnhw bimselfentir%y to the spacialty for which he was trained, and if he pos- sam his soul in patim# while he waits for his practice to develop. I h v e m y b given just that advice to young surgeons who consulted me about their futux, and I a n think d fetv who have not eventidy a d .

The r c f d of paticno to hosphh has in- ertas6dinordhtcly~thtpastseetralprsas hospital bcd apcity has rism. The emnomic side o f d h ~ , f b r t h i s a n d o t h c r ~ , h a s b e t n brought fomefdy to the p a t h f s aretotioo, The surgeonhasrrighttoexpectaperxlniatyreward f o r b i s m . HchasIdcals,buthctoomust live. I wish, howcvw, that 1 muld impms upon pmgmmwhoarejustsEartiPgthepracticeof ~chat~eRismOrcthantbtfinnnlrinlsidet0 surgical sums. I wish that 1 mutd sham with themmyowneXperi.enoeandmakcthmrtalizt that h c t , proficiently, p a t i d y and willingly pedbmd, is thc foundation upaa which pmh- i d stws and happiness et.t founded. It is hard to reaIize this when m e is just starring out, but it is e t d y true. Finanad rewards are im- pmnt and nmswy, but they are automatic and of b c r mnquence than the satisfaction that cxnnear from duty well done. If these mncepts could b put into practice, we should soon hcar no more of cxorbirant fees, out of all pqortiw to the d c e s rendered and the ability d patients to t o h t e them.

One phase of ywr dtiansbip to the went, the , public and the press bas been emphasized many

f i m c s b e f o r e ~ o f t h i s ~ Magnu- p o n d d a t t t n t i o n m i t i n h i s ~ ~ a t the $an Frandxo Congms in 1951- I refer to what Dr. C J c E M i l k r ~ d ~ ~ humnitkid d c i n e . We ham advpnoed fjrr in ~~ me&- cine, but as we haw - we bve too Ere- qucntlg hrgotm thc tcIaliomhip which - =- is& betwleen physidan d patient, and which the patientstillnosdsdgearnsfw.

The physidan must bc advisor and friend ifht is toM6lihiswholefundion.ThismIemustbeem- p&aniztd. Pathw rtgtnt i m w care, rrnd al l too often they nmiv~ it in group ptacticc, in teaching caers, and cprn in private practice. It = Y ~ = = w * t * P = - g h ~ ~ hands d undugu many tcm, but surely along theway~~~~taktimcforaWWC1of~lanst ion and &em and anything else tbat will help to re- stom the old-, bappier &tionship.

SURGEON, TAB PR-ON AND COLLEGE

In many r e s p surgeons carry thc hmvicst rqmdm€s of all p h p s i h $ if only bust of the laam thcy can do. For th is reason it is aseatid chat they never forget what thcy are uadmakhg when they lay hands upon the human m y . This is one mpm in which I think m d d eduaation has ken d p b l y re&. It b mat ia l that we dettr- mfne a mat intelIechml -padry and training before we allow him to kgh the study ofmcdi- c ine ,burweshddnzakef j i rgreater~rbao we art now making to debmine bi +ti- of heart and spirit, and we &odd dml upon those things thoughout dl his day in medical -1. Thae arc qualitia, ofmum, which stcm from tris M y beckground and early trahhg. We must have some hmchb u p which to build, and it would pay us to look more deeply into it before we accept my a d d a t e for a medial area. We should k certain, to use another old-hhined phmc, that he has a w d o n to medicine. Those of you who hove tMertd the pmf&sion in that spi&dlootneedthcmnhderdwhatf am ~ y i n g w you tonight.

"Corr#mpt fw &tiad dues," wmtc a fa- mws c o l ~ , "ad thc a m h i d o n of e t h i d

well as adoclineindccorumwitha dcfautt of m, mmn, and prindpie, are the chnmeristicar of a decaying society which

wontimed Qll 59)

[e; Third Inter-America n Session

Tm TIME is NOW! The prescription is m d y to be filled. Mary a surgeon has been promising him- gtlf he would take some time for refkesher 00- and brush-up developmenm in

breath he &Is a leaving his wife

hundreds of other surgeons on board; and dis- eussts and examines new items of surgid equip

he Responsibility of a Heritage

mmt. Mcanwhilt, his ship is guiying southward and by New Year's Eve he is mady for the bilq shipbard celebration. O n New Year's Day he is

t. Thomas. in Marthiqut and on

intriguing porn, with ashore in major cities and aboani

horrcr stop, until he maversa and lands at Cdho, tbe port

city &Lima, Pcru, to attend the Third Inter- Amtrim h i o n . Thc meeting offers amctions in all surgical sphldes, and hospital chic1 and joint =ions with the Peruvian Aadcmy of Sur- gery. Whik in Lima he visim with distinguished surgeon wlleagues fmm all the Latin Amerimn wuntrie and sees somc of the historical pint8 in and around that city.

His ship, waiting for him at C a b , brings him bck through the M, and stops at Mba, Crisrobal, Ugston, Port-au-Prince, Havana, Nas- sau and New Yark. Lading surgeons in the

York thc pmcrip theramtic effeFts

arc re-

t show themselw in advance of allam." Are some But the mhiug of young men to s d older of our professional shcirtmdngs but pan of an mcn is not only a duty well performed, not only a wolutimry cycle? Is the trend irrevcrsibIe? For h c c : to& our Wow men, but also a lasting my own part, I refusc to betieve it. I prefer to ac- spiriturrl satisfaction to thc surgeon himself. q r the challenge of the future. The p a l of our With this College for the backpound, with thc profasion is still service. The memorials left be- opprtunitim and resgmmibilitics which Fellow-

- hind by elder surgeons are the young men whom ship in it bestows, deviations in moral rectitude are they have trained in a profession that is still both a incompatible with thc traditions of tbe pat . It is science and an art. Thae arc enduring, these are he function and duty of this ColIegc, of which you monuments m e p s r d , morc bring than brass. newly admined FcUows are the youngat acoIyres, Tecbnid procedure may k changed within a to carry forward the torch in a manner eollsonant short space of p m . The dhmvcrg of some ncw with our heritage. This, indeed, may be our des- technique o f h a n d i d may shortly be overturned tiny. - by the discovery of mother and better techuique. -

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