Presumption, Privilege, and Preemption

The title I have chosen is meant to be obtuse, but I hope not gratuitous. I chose the title because I thought it would allow me to focus on 3 aspects that were important to me. First, presumption. It is to some degree presumptuous of me to be speaking from this lectern to this group, characterized so clearly, as the leadership of American surgery. The people who have preceded me in this office have led the leaders, both within the surgical profession and within medicine, in its greater context. I hesitate to refer to specific individuals for fear I will do so inadequately and only highlight my own deficiencies when contrasted with many of them. It appears traditional and appropriate to at least acknowledge the debt one owes to one’s teachers and colleagues as they are the key to one’s own success.

One is always tempted to refer, in one form or another, to the fact that one has done as others have, and “stood on the shoulders of giants,” only by that means allowing one to see as far as one could see.¹ Actually, I have been favored, much as a child is favored when sitting on the shoulders of their father, not to see further, but to see it all and to be carried along without effort and in moderate comfort. Not surprisingly, it will be impossible for me not to include from whence I came, where I have been, and what I am now doing. The presumptuous nature of my existence was never more highlighted than following the death of Francis D. Moore, Sr (Fig. 1). Note well the right upper-hand corner, “If they can operate you’re lucky.” Because I was asked to comment and reflect on his life, the awareness that I had walked in his shadow and been carried upon his shoulders was never more evident.² It was he who gave me the opportunity to study and work in this country. From that single opportunity, I came to live a professional life of which I could not have dreamed. As I stand here today, I wish I had more of his legerity, so often demonstrated at this meeting. Dr. Moore, thank you.

FIGURE 1. Francis D. Moore on cover of Time magazine May 3, 1963. “If they can operate, you’re lucky.” Used with permission from TIME LIFE PICTURES.

Second, it was my privilege to have been born in a wonderful country. My parents never knew hunger, want, or need and were exposed to few, if any, natural disasters. They had access and capability to provide for me an education that would allow me to take advantage of opportunities, in the future, of which I knew not.

I need not remind this audience that our birth is the product of a genetic lottery, one in which we have no say, no choice, and yet are favored by being born into a world where maternal and infant mortality is low. I was born in a country where the climate is mild with few extremes and into a society where quality of opportunity was essentially a given. My parents lived through the Great Depression but again in a society that was protected and immunized from many of the effects felt in other parts of the world. I was born at the beginning of World War II and failed to appreciate the horrors of that conflict and its impact on others until I read of the bestiality and mind-boggling stupidity of such conflicts many years later. My father, who had one brother killed and another seriously wounded in World War I, spoke little of the conflict that he, by an accident of time, place, and contributory privilege, was to avoid during World War II. I went to medical school at a time when less than 8% of the graduating high school population went to a university or college. Medical school required fierce competition to gain entrance, but I was never aware of that. Medical school, once you were in, was difficult to be dismissed from! Under the New Zealand system, if you were a good enough rugby player to converse with the professors after a match and allow them to relive their youth with your activities on the playing field, you were unlikely to fail!

There was only one disadvantage of this privileged education, and that was that I finished my education thinking life was just a game to be played, to be enjoyed, and for which there was very little price. It was not until I realized that while the medical school thought that they had given me a degree in the healing arts, they had indeed armed me with a license, which had I used it without thought, was a license for carnage. It was only after medical school that I realized that I had an obligation to take advantage of this privilege and try, if not to contribute, at least to do little damage. The Royal Australasian College of Surgeons gave me my initial training, and I recognize our most recent honorary member, Dr. Russell Strong, and our honorary fellow of 1989, Dr. Tom Reeve, as paragons of that organization. I was in this process when Francis Moore came to New Zealand. To this day I do not know what he saw in me other than an unmarried surgical resident who had unlimited time to deliver him from place A to place B and almost always on time! As I mentioned, it was he who gave me the privilege of coming to Boston and the Brigham. Dr. Moore also gave me the privilege of knowing many people who would forever influence my life and assist me to achieve whatever I could. It is hard not to spend the rest of this presentation thanking the truly innumerable friends, colleagues and associates who have helped me become a better person than I deserve. It is important that I highlight some to give a flavor of my privilege.

It was at the Brigham that I met people such as Bob Bartlett, who won the Medallion for Scientific Achievement of the American Surgical Association (ASA) last year. I take pride in the fact that he introduced me to clinical research at the Brigham. I was involved in some of the very early studies he initiated utilizing the incentive spirometer, and subsequently extracorporeal membrane oxygenation. But, in case you think I deserve any credit for those studies, I would remind you of my role. First, in incentive spirometry, I was such an important contributor, that at the time of the publication of the final manuscript, Bob could no longer remember my second initial!³

It was at the Brigham that I first met Steve Rosenberg, who was the ASA Flance Karl Awardee last year! Steve had started the residency about the time I started my own in New Zealand. He had gone away to complete a PhD or maybe two, and had returned to join us in the senior year.

Friendships made at that time are impossible privileges to underestimate. The friendship of people within that residency program the Nick Tilneys, Bob Quinlans, Alden Harkens, and so, so many others, is irreplaceable. It was Alden who introduced me to research at the VA, again as the willing gopher, although the West Roxbury VA was far enough away from the Brigham for Dr. Moore to ignore our efforts!⁴

It would be inappropriate for me not to emphasize that while I met Ned Cabot as a resident, he has remained my friend these last 30 years predominantly outside of medicine. It is he who has taught me that there is a world to be lived, and the chances I have had to join him to ski, to sail, and to hunt have provided a balance in my professional life that can never be underestimated or adequately repaid.

There were many others in those formative years in the 1970s that gave me far more than I can ever repay. Intellectually, Dr. George Cahill taught me, in a totally different way than Francis Moore, about metabolism and encouraged me to take techniques used to evaluate diabetes and apply them to the metabolic defects of the cancer patient.

It was Steve Rosenberg who gave me the opportunity to go to the NIH to join him as he set off to develop the most respected, focused and committed program in human immunotherapy. Even now, despite those 6 years at the NIH, I shudder at my ignorance of the extraordinary contributions he has made.

While at the NIH, I was encouraged to further develop my interest in endocrine surgery. It was the extraordinary resources of the NIH that allowed what success we might have had. The keys to that endeavor were many people, not the least of which were John Doppman, Phil Gorden, Jacob Robbins, and Gerry Aurbach, among many others.

Finally, my privilege was complete when I moved to New York to join the staff of Memorial Sloan-Kettering Cancer Center. It is hard in retrospect to convey the unanticipated honor that it was to join that institution, and I take great pleasure and much pride in having helped to further develop that surgical department. The key in my early development was my recruitment by Dr. Jerome DeCosse and the encouragement of the Physician-in-Chief, Dr. Samuel Hellman. However, it was not the people above me who were the source of my success, but rather it was the people beside me, and the people who came to work with, and for me that made the difference, particularly the division heads, then and now. Any recognition attributed to me belongs to them.

Although New York is now a different place, many of those faculty members are present today, and I want them to know, as individuals, that without their personal effort we certainly could never have done what we have done. The young faculty, that I have watched grow, has enriched me enormously, and I only wish that I could have said more and recognized them more than I ever did. The untimely death of my young friend and colleague, Michael Burt, made me realize that one could never say enough or express often enough one’s respect, admiration, and indeed on occasions, love that one has for a fellow friend or colleague. To this day, I do not, but wish I would, thank people enough, inspire them enough, or even provoke them enough, and my excuse, used by so many of us, of too little time is just that - an excuse. So to any of my faculty in the room and to all who have helped me, I express my heartfelt thanks and hope that they will in the same way, express to others around them, my admiration and respect for how they make all of us look better than we really are.

So, I have built a career on presumption and privilege.

How does one acknowledge the ultimate privilege of having a family, who despite the demands of a surgical career, seem capable of accepting their loss as my privilege?

Now, the third “P.” Is there any substance to this oration? Am I going to continue in this gallimaufry manner? I would like to leave you with some comments that have at least some substance. The third “P” is for “Preemption” and I wish to use that in the concept of preemptive surgery.

There is an ever-occurring revolution going on in surgery. Sometimes it requires that we step back just to realize how drastic and dramatic the changes are, and have been, in our own professional lives, which amid the day-to-day struggle seem to be constant and unchanging, but they move in an inexorable way. Perhaps not like turbulent rapids, but rather like the deep, forever strong, and fast flowing rivers often associated with time. The challenge of preemptive surgery comes about because we can now define at the time of birth the genetic probability, and indeed in some situations, the genetic absolute of the development of disease.⁵ The consequences of this are huge. For example, in familial medullary thyroid cancer, the genetics of which have been hugely contributed to by a former president of this organization, Dr. Samuel Wells, another giant who has carried me, and whom I consider a great friend; we can now say, at the time of birth, or even prenatally, with essential certainty that a patient will or will not develop medullary thyroid cancer, which if untreated will ultimately be the cause of their death. This allows for preemptive surgery at a time when the malignancy is not present, where the malignant precursor is barely engendered and death from medullary thyroid cancer is presumptively assured. The consequences of this ability to provide a preemptive strike, however, are dramatic.

The first consequence is that patient care is becoming disease-focused not discipline-focused, ie, patients will be expected to be cared for in an environment based on disease rather than method of treatment. To do this, access will come through extent of knowledge not through availability of technique. That knowledge will be highly predicated on the accuracy of diagnosis and genetic risk.

If we take soft tissue sarcoma, something that I have been interested in for these last 30 years, we characteristically make the diagnosis and characterize the subtype by microscopic examination of hematoxylin and eosin and subsequently by immunohistochemical stains. This has changed entirely, however, from the time of James Ewing, a former director of Memorial Sloan-Kettering Cancer Center, who, when he first described his sarcoma, lumped together a large number of entities which we now know to be quite distinct. The availability of methods to examine the Ewing’s family of genes now allows us, with near certain prediction, to determine that the Ewing sarcoma and the primitive neuroectodermal tumor are the same entity, both sharing in 95% of cases an abnormality in the FLI-1 gene. In similar manner, other lesions, such as myxoid liposarcomas, are characterized by a TLS/FUS fusion gene in 98%.⁶ This marriage of entities by molecular diagnosis allows us to both unify and discriminate between tumor types thought at one time to be the same. In addition, it allows tumor occurring in what was considered an unusual site, to be designated as to its true histopathology.⁷ An example is the finding of synovial cell sarcoma in sites such as the prostate, perineum, kidney and the tongue.⁸

In similar fashion, Ewing sarcomas were classically thought of as tumors of the adolescent or young adult, but are now being seen in patients in their 8th decade. Similar commentary might be made for desmoplastic small round cell tumor and alveolar rhabdomyosarcoma.

However, these near absolute designations are only the beginning. We can now use molecular diagnostic techniques to distinguish similarities of genetic expression that would help us designate potential behavior.⁹ Using the current relatively primitive tools of gene analysis, and the various methods of cluster analysis, the details and vagaries of which will continue to be worked out, we can put together a cluster of genes for a large group of sarcomas and partition those both in 2-dimensional and 3-dimensional ways to see where they cluster and to what they are similar. An ideal example is clear cell sarcoma. Historically thought of as a sarcoma but also called melanoma of soft parts, is it really a sarcoma or is it really a melanoma? When we performed an analysis of a group of tumors, both melanoma and soft tissue tumors, including clear cell sarcoma, we were able to show that in fact clear cell sarcoma clustered with a similar genetic pattern to that of melanoma quite distinct from other soft tissue sarcomas.¹⁰ This technique, either supervised or unsupervised and focused or not on a particular set or group of genes, makes the distinction even more clearly. So we can more comfortably now say that clear cell sarcoma is really a molecular subtype of melanoma. This explains the behavior of clear cell sarcoma, which acts like that of malignant melanoma, and presumably is more appropriately treated as a melanoma. Such analyses are in their infancy and demand huge progress in information technology analysis, and methodologies for bioinformatics to determine how we will best use such information, certainly in a diagnostic sense. The overwhelming volume of information available makes the simplistic biostatistical methods that I was weaned on, obsolete.

But how does this relate to preemptive surgery? Although disease-based surgery will mean much more centralization, there will be centralization of diagnostic interpretation; there will be centralization of risk evaluation; and potentially centralization of treatment.

Perhaps more importantly, however, prophylactic or preemptive surgery will require ever increasing technical perfection at a time when we perceive that technical aspects of surgery are undervalued by our nonsurgical colleagues; rather technical excellence is becoming even more important.

The concept that we can change outcome percentages by adequate operations, even if only by stage migration, to a greater extent than the percentages seen in many adjuvant studies, should not be lost sight of.¹¹

If we are going to indulge in preemptive surgery, then society will begin to demand risk-free operations. If we go back to our original example of multiple endocrine neoplasia and the need for childhood thyroidectomy, once the presence of the RET proto-oncogene has been identified, then will parents accept any risk of complication either as hypoparathyroidism or recurrent nerve injury if the thyroidectomy is to take place before the age of 5 years? If one examines the recent literature as to recurrent nerve injury, it is quite staggering to see that temporary and permanent nerve injury occurred in published series in 4-18% of cases!^12,13 Obviously, these procedures, performed 10-15 years ago, are no longer considered standard or acceptable. That alone is progress. We take too little credit for the fact that we have improved and continue to improve, operative morbidity and mortality. However, in prophylactic thyroidectomy one would expect that there would be no operative complications, and Dr. Wells has previously shown that this is certainly possible.¹⁴ But this requires focused endeavors in a very specialized unit. Clearly, this preemptive surgery translates into benefit for the patient, with the death from medullary thyroid cancer markedly diminished or eradicated by early thyroidectomy.

Molecular diagnosis can take this further because, as we examine the underlying mutations within the abnormal gene or genes, various specific mutations can be used to project the likelihood that one would develop medullary thyroid cancer based solely on the type of mutation identified.¹⁵ This entire concept, that we will be able to predict not only the development of specific disease entities but predict who is most likely to respond to a specific treatment, is in its infancy, but can be expected to be defined in the next generation. Already studies exist to define populations and individuals as to their likelihood of response to an environmental (in the broadest sense) agent, by disease development.

So, preemptive surgery will create more disease-based and not discipline-based treatment. Society will demand a risk-free operation and greater emphasis on potential morbidity and mortality, and alternative options will occur.¹⁶

Let us examine a more common operation. What about preemptive surgery for familial adenomatous polyposis? It is well-established that patients with this disease who undergo total or near total proctocolectomy decrease their risk of colorectal cancer.¹⁷ But what is the preferred operation? What is the measurement or are there measurements to judge the preferred operation? Total proctocolectomy obviates cancer risk, but society is focused not just on the prevention of malignancy, but on the complications and risks of such procedures. Quality of life issues become essential as one begins to examine the consequences. For instance, in ileal pouch anal anastomosis, the considered appropriate treatment of this disease, there is significant morbidity with leakage of 43%, and food intolerance - all significantly different from the conventional, relatively simple ileorectal anastomosis, within the capability of the majority of surgeons.¹⁸ Encouragingly, overall health scales are equivalent. What is the appropriate procedure? How well should the patient be informed of this preemptive operation? What other issues should be determined? Should the patient be informed that fecundity, the biologic ability to conceive, is an important issue? A recent study suggests that for patients undergoing operations for familial adenomatous polyposis, the ileal pouch anal anastomosis decreases the likelihood of conception by a factor of 50-70%, when compared with ileo-rectal anastomosis.¹⁹ How much of this should be considered in the discussion of preemptive operations for inherited disease? Who should make the decision as to what the real consequences are? Independent evaluation of outcome will become mandatory.

If we take the issue further to hereditary nonpolyposis coli, where multiple different genetic events have been identified with mutation frequencies of the order of 50-80%, the precision upon which we make decisions for preemptive surgery becomes much more difficult. Clearly, there is a reduction in the life-time risk of colorectal cancer by subtotal colectomy of the order of 80%,²⁰ in comparison to those continuing under surveillance where the life-time risk is decreased by about 60%. Is that 20% margin sufficient? How does one figure that in terms of operative mortality? These are issues that have been studied. Health care providers, ie, the payors, examine these issues constantly. They would say fairly clearly that if the life expectancy gain of surveillance endoscopy is 13.5 years and the life expectancy of prophylactic colectomy is 15.6 years,²⁰ then maybe we should determine what procedure is to be done solely on cost! We need to understand what the informed patient wants, not necessarily what prophylactic operation that we have accepted as the preferred procedure! Nor should we allow the procedure to be one that the payor sees as the most cost effective.

Perhaps closer to my own interest, what about gastrectomy? We now know that inherited gastric adenocarcinoma makes up perhaps as much of 1% of all gastric cancers, a chromosomal dominant high penetrance mutation of the CDH 1 gene.^21,22 In those patients there is a cumulative risk of gastric cancer by the age of 80 of approximately 67% in men and 83% in women, with an associated increase in the woman of a risk of breast carcinoma.²³ Preemptive total gastrectomy has been performed in many parts of the world.^24,25 In those patients, asymptomatic but with germline e-cadherin gene mutations, multiple foci of carcinoma were identified in all patients operated on between the ages 22 and 47, despite the absence of any symptoms!

As the operation becomes larger, the issues of operative mortality assume greater importance. What is the accepted operative mortality for total gastrectomy? In the last 60 years operative mortality for total gastrectomy at our Institution has gone from 20% to 4%, and is now 2.5%. Operative mortality in other reported series in the years 2000 and 2001 continue to be as high as 10 and 15%.^26-28 What is the morbidity of such procedures? What are the consequences after total gastrectomy of an esophageal leak? How many patients without proven malignancy will die of the procedure? Just one death in a preemptive or prophylactic operation can seal the fate of that approach. Look at the consequences of a donor death in living related donor transplantation! What are the consequences of total gastrectomy for a life-time? We know that there is weight loss, malabsorption of fat, lactose intolerance and dependence on folate and vitamin B12 supplementation. What does this translate into over a period of 50 years if the gastrectomy is performed at the age of 22?

Let us make it even more challenging. It is now clear that at least a small cadre of inherited pancreatic cancer exists, with familial cancer syndromes and hereditary pancreatitis. So far, absolute genetic profiling and prediction is not possible. Nevertheless, some studies have identified abnormalities in germline BRCA2²⁹ and it is expected that many others by cluster analysis or other techniques will provide a high probability of identifying patients who will develop pancreatic cancer. Should those patients undergo total pancreatectomy? This has already been proposed³⁰ and suggested that “it seems reasonable to proceed to total pancreatectomy” and this has been done.³¹ In the latter study 10 of 35 high-risk patients have had total pancreatectomy, histology demonstrated dysplasia but no cancer. Are we ready for this aggression? How certain are we that dysplasia proceeds to cancer; how long would it take? It seems surprising that such an approach would be easily approved by an institutional review board or ethics committee in the United States.

When we looked at total pancreatectomy and long-term follow up, it is not a benign procedure.³² There is diarrhea, severe diarrhea in 10%, significant bone loss in 100%, and in fact, when we looked at survivors who were cancer free at 5 years after total pancreatectomy, of the 7 patients examined metabolically, 6 had hepatic insufficiency and 3 died of hepatic failure predominantly from fatty infiltration! The follow-up of those recent total pancreatomized patients³¹ will be imperative. At present it is 1 to 48 months and none of the nonoperated patients has developed cancer. What is the correct approach? The consequences of this type of procedure will make partitioned transplantation, ie, transplantation of the benign islets following the resection of the premalignant but malignant designated carcinoma of the pancreas, even more important. Tissue engineering and transplantation will receive further emphasis.

This has already begun to be examined, as we transplant the 3-13% of cirrhotics who have an undetected underlying hepatocellular carcinoma.³³

At the present time, outcome analysis is in its infancy and is being led by surgeons because of the ready availability of operative mortality statistics.^34,35

Institutional surgical volume has become an important surrogate for decreasing mortality and morbidity, and as they are readily identifiable numbers, will become increasingly available to the public. It is now quite clear that for gastrectomy, as with other major operations, volume does matter, as seen in the New York State data for 1994-1997, for hospital and surgeon.³⁶ The operative mortality varied from 11.2 to 2.9% dependent on hospital volume. We shall never be able to avoid the occasional, emergent technical procedure, but how many elective hospital or surgical procedures is enough to maximize benefit and minimize risk? If volume is so important, how do we address institution and surgical variance in mortality rates when such are readily available to the public? When we analyze the impact of hospital and physician surgical volume on inpatient operative cancer mortality, in New York City there was a variance between the high-volume surgeon-high-volume institution and the low-volume surgeon-low-volume hospital of 3 to 9%. How can one explain that to the public? Normally, one will not go for ones preemptive operation where the mere act of walking into a different door a few miles apart changes the outcome by 300%! It is not only operative mortality, but overall mortality that is volume dependent, emphasized by examining overall hospital mortality rates with or without an operation.

It is, however, becoming progressively clear that all major operations do not and cannot be done in single centers. The challenge is to discover at what point and what number of cases by either institution or surgeon, does mortality reach an acceptable low level commensurate with the high-volume institutions. The analysis at this meeting of the “leapfrog” criteria is an excellent first start.³⁷

The issue becomes to determine what level of operative experience is the hospital or surgeon to achieve to result in acceptable levels of mortality and morbidity? One can see that when we examine the experience of ourselves as a tertiary care cancer center compared with other institutions in the same geographic area, the low mortality in a high-volume institution such as ours is reached very early, with low-surgeon volume. Conversely, the low mortality in other institutions is not reached even with as high as 30 procedures per physician, suggesting a strong influence of institutional infrastructure, presumably in both facility and personnel. The likelihood that one would receive an operation in a tertiary referral center by a surgeon who does >30 procedures a year is in excess of 60%—this number is <20% in other less specialized institutions. There will have to be some degree of marriage between defining limits by individual operation for both institutions and surgeons. This should not be particularly difficult, as very few surgeons are interested in doing a single complicated case each year, particularly if performed in the environment of lack of appropriate support services for that procedure. The challenge will be how this will be defined. Try to envision a definition of a level of care which will allow a certain number of elective complicated procedures to be done within the institution, given the understanding that emergent procedures will always need to be done and will be expected to have greater morbidity and mortality.

Clearly, that concept will be modified according to the geographical area along with some of the legal requirements now in place, as to the appropriate and acceptable standard of care.

In summary, preemptive surgery will result in more and more disease-based rather than discipline-based surgery. Society will have increasing demands on risk-free operations. There will be far greater emphasis on potential morbidity and alternative approaches. In situations where complete organ removal occurs, particularly organs with dual function such as the liver or pancreas, increasing emphasis will be made in developing strategies for transplantation both in terms of tissue engineering and xenogeneic transplantation.

But, who would accept such genetic testing or screening? This, too, has already been studied.³⁸ An interesting study examined members of the National Society of Genetic Counselors, who, if told they had a 50% risk of BRCA1/2, 85% would be willing to be tested for it. If they were positive at the age of 35, 25% of the women would have a prophylactic mastectomy, but 68% a prophylactic oophorectomy. What are the consequences of oophorectomy at age 35?

The exciting observation³⁹ from our institution that salpingo-oophorectomy in patients with BRCA mutations compared with surveillance decrease the incidence of breast and ovarian cancer, raises the exciting prospect of one end organ ablation decreasing the risk of cancer not only in that organ but in a remote organ!

If they were tested positive for Hereditary Non-Polyposis Colorectal Cancer (HNPCC), who would, in fact, accept operation? 91% would pursue testing, but only 17% would pursue prophylactic colectomy, and 56% would pursue prophylactic hysterectomy. Far different from that which one might have suggested based on known risk of malignancy, but clearly emphasizing that the potential morbidity and mortality of such procedures does color the attitudes and decision of patients at genetic risk. Previously it was the physician that decided who should or should not have a prophylactic or preemptive operation. Given the availability of such information electronically, the most remote of patients will have the same information, and may well make a very different decision than his or her physician advisor.

What are the consequences? How much psychologic help? What are the insurance company issues? It is clear from this study that the majority would not bill the insurance company, and presumably would do everything within their power to keep the results unknown. Imagine the difficulties the physician and surgeon will have. Given the requirements of the Health Information Portability and Accountability legislation, we must keep such information confidential.

Similar studies have been done in patients of families known to have BRCA mutation. Of over 600 individuals at greatly increased risk of a DNA mutation, less than 50% accepted the opportunity to be tested. Socioeconomic factors were important, and again patients chose bilateral salpingo-oophorectomy over mastectomy given the subsequent risk of death from malignancy.⁴⁰

And what are the consequences of training. Training is already undergoing evolution with more and more focus, as emphasized previously, on disease-based rather than discipline-based. We now have integrated residencies in vascular and interventional radiology and many more can be expected to come. Progressively, training will be led in disease-based systems, as is already identified in trauma and oncology.

I believe earlier differentiation and specialization will inevitably occur. We have never had a problem with the fact that orthopedics and neurosurgery, after 1 year of introductory general surgery, have moved on in to their own discipline. Progressively, the trend will be to move on into more disease-based rather than discipline focused entities at an earlier stage of training.

The surgeon can either be assigned the role of a pure technician in an area controlled by a knowledgeable disease-based specialist, or can take up the challenge and becoming that disease-based leader so desperately needed.

Conversely, if on the one hand we develop earlier differentiation, and subsequently earlier specialization, how will we cope with the demands still present for the generalist for the delivery of surgical care in smaller less concentrated populations? There must be room to develop those generalists who are capable of delivering surgical care to a wide spectrum of relatively uncomplicated disease. One can imagine, however, the development of a generalist as a true specialist, as has been done in other parts of the world with the development of what is called “rural” surgery for want of a better name. Such surgeons require the same degree of respect, self-fulfillment, and recognition of their broad talents as does the highly focused disease-based specialist.

With the increasing restrictions on hours of work, there are inevitable developments that cannot be avoided. Clearly, there will be increased demands for technical perfection, particularly in any form of preemptive surgery, and there will be much greater emphasis on minimally invasive surgery, but at the same time much greater oversight, validation, and outcomes analysis. All of this will be readily available, and scrutiny of the surgeon and surgical performance, along with disease management performance, will be performed not only by the profession, but by oversight and regulatory bodies. In turn this information will become freely available to the public in an “on-line” basis. This makes the deliberations of the combined American Surgical Association, American Board of Surgery, and American College of Surgeons “Blue Ribbon Panel” even more important as a potential framework for training in the future.

What else have we not examined? We have not even begun to examine the consequences of preemptive surgery in terms of consent, insurance, mandatory versus voluntary, litigious consequences of a false diagnosis and multiple others.

And how do I see all these as yet unchallenged problems? I see only opportunities for growth. The growth of surgery, as an integral leadership component of most disease management systems, is inevitable. It requires only that we accept the challenge—surgeons are ideally suited to such leadership roles.

I have focused inordinately on cancer, but the same can be said for other disease based approaches, many already established, in trauma, and vascular disease for example.

What greater excitement for young people than to enter a world defined by genetic preemption, allied to great personal and professional growth opportunities? I have been privileged to be exposed to young surgeons in training who have helped me keep my surgical conscience, enriched me beyond measure, and gone on to make this a better place for their friends, colleagues, families and patients. Little does the student know how much he or she fosters the growth of the teacher. The opportunity, however small, for any one person to favorably influence the growth of another is a true privilege.

And what is it really all about? This is a little about presumption, a lot about privilege, but not too much about preemption. It is a lot about you, about your privilege - your privilege to care for another human being. How do we accept that we have the tools of preemption, but need the compassion and insight to establish the courage to do what is right?

And how do I end? I began with presumption, grew on privilege and have shared some of my thoughts on preemption with you. I would like to end on privilege. It is a great privilege to have been given the opportunity to spend a life as a surgeon, a great profession, and to be adopted by this country that, despite the current travails, is still, and will be in the future, a country of great opportunity founded on great principles.

Thank you.