American Association of Endocrine Surgeons 2014 American Association of Endocrine Surgeons Presidential Address: Evolution Sally E. Carty, MD, FACS, Pittsburgh, PA
From the University of Pittsburgh, Pittsburgh, PA
EVOLUTION IT IS A GREAT PRIVILEGE to address this superb 2014 meeting of the American Association of Endocrine Surgeons. Once again we have record-breaking attendance. In the beginning, were the Bylaws. I’ve been told that this Presidential Address should be about what is important to me, while reflecting the mission of our society and what is important to its members. This address is therefore, about your society, the American Association of Endocrine Surgeons (AAES). To me, transparency is also important and as AAES becomes larger and more complex, we want to keep all members productively in the loop. Thus, interspersed with some personal wisdom, in this article I provide you with state-of-the-union exposition of some of the important initiatives for which an army of people have cheerfully done huge amounts of volunteer work this year as the AAES evolves into the vibrant, intelligent, busy society of today and tomorrow. And because this year’s theme was education, I will also give some concrete suggestions to our AAES candidate members. Endocrine surgery is a relatively new specialty. Its identity is driven in large part by the increasing complexity of today’s management of surgical disorders of the thyroid, parathyroid, adrenal glands, and neuroendocrine pancreas.1 In the Accepted for publication August 21, 2014. Reprint requests: Sally E. Carty, MD, FACS, University of Pittsburgh, Pittsburgh, PA. E-mail: [email protected]. Surgery 2014;156:1289-96. 0039-6060/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.08.072
past, these diseases were incompletely understood, and even today are often missed. Endocrine Surgery has actually been practiced for over a century, as summarized from the works of Dr Richard B. Welbourn and Dr Janice L. Pasieka.2,3 In the 19th century, there was resection of endocrine glands for enlargement and neoplasia; at the turn of the century, as hormones were discovered, there was surgery for hypersecretory states; and in 1948 the release of cortisone for medical use allowed safe adrenalectomy. Next, surgeons like Dr Oliver Cope began to focus on the physiologic responses of surgical manipulation of a diseased organ while the APUDoma concept also took hold. By the time of Dr Richard A. Prinz’s Presidential Address in 1996, there were 70 approved US residency programs in general surgery that had at least one endocrine surgeon on faculty.4 More recently, the AAES has developed curricula for residency training in general surgery and for fellowship training in endocrine surgery, as you will see in more detail below. The AAES was founded in 1980, with the bylaws initially drafted by Dr Jay Harness,5 and our beloved Dr Norman W. Thompson was the inaugural president of the AAES. But by 1990, when I began going to meetings as a fellow in the Surgery Branch of the National Cancer Institute, it was basically still a club---of smart, nice egalitarian people in a surgical world that at that time was unfortunately not always nice. Today however, endocrine surgery is a rapidly growing specialty with a unique personality, a personality that is due in large part to the responsible, generous natures of many prior ‘‘greats,’’ some of whom I will mention below, and others of whom include Dr Timothy S. Harrison, Dr Edwin L. Kaplan, Dr Orlo H. Clark, Dr Paolo Miccoli, SURGERY 1289
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Dr Jean-Francois Henry, Dr Stuart D. Wilson, Dr Bertil Hamberger, Dr Per-Ola Granberg, Dr Colin F. J. Russell, and Dr Janice L. Pasieka. These true gentlepeople have been and are my role models, and I thank each of them very kindly. In full disclosure, right from the beginning the AAES has been unlike other professional surgical societies, being characterized by a particular brand of friendly, creative curiosity and by a strong interest in best results for patients. To perhaps overstate it, while it is true that endocrine surgeons are smart, detail-oriented nerds who love to talk shop, we also embrace change easily and we work notably hard to prospectively and objectively advance the field. We love to use complicated tumor markers, perform delicate surgeries, and invent intricate management algorithms, but we also prize clever, directly practical care. Endocrine surgeons also stand out for the habit of reflection, a true joy in mentoring, and a bias toward collaboration, which is often multidisciplinary in nature. An obvious example of the collective spirit was the work of Dr Geoffrey B. Thompson, culminating in the 2008 vote to admit our allied surgical colleagues to membership. AAES members are also enthusiastic volunteers, as our new administration company BSC Management Inc is learning: ‘‘OK how about we do a trip to the Moon! Great idea! Is it feasible, and who else wants to work on it?’’ Energy is our heritage, but no matter how much we wish to take on for patients we also consider that, as Robert A. Heinlein said in his marvelous novel The Moon is a Harsh Mistress, ‘‘there ain’t no such thing as a free lunch.’’6 As I detail the AAES9 evolving initiatives, it will be good to keep in mind that dictionaries variously defines evolution as (1) the process by which living organisms are thought to have developed and diversified from earlier forms during the history of the earth and (2) the gradual development of something, especially from a simple to a more complex form. Wikipedia Inc, which today has replaced the oracle at Delphi---in fact during thyroidectomy, we should call it the Wikipedian lymph node---lists the mechanisms of evolution that we all recall so clearly from medical school as: Natural selection, mutation bias, genetic drift, genetic hitchhiking, and gene flow.7 And because the AAES is all about outcomes, let’s also keep in mind the potential outcomes of evolution, which are adaptation, coevolution, cooperation, speciation, and extinction. A BRIEF HISTORY OF AAES FELLOWSHIP TRAINING Evolution is gradual development from a simple to a more complex form. In the words of Dr Tracy S.
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Wang, as medicine evolves, the perioperative management of patients with hormone-secreting tumors has become increasingly intricate and refined.1 At the same time, endocrine surgical care has also become more centralized to those with best outcomes, leading to a higher standard of care that Dr Pasieka in 2009 described as a classic positive feedback loop: ‘‘A higher standard of care in focus areas stimulates research, and research in turn improves the quality of education and training. which leads to better patient care.’’3 In 1996, Dr Prinz called for the AAES to develop defined educational goals and objectives for the extant apprentice-type postgraduate training available in endocrine surgery.4 This call has since been refined and extended by a number of our leaders. In 2005, the AAES Education and Research Committee developed a formal curriculum for fellowship training. That year there were 11 fellowships listed on our website (9 in the United States and 1 each in Canada and Australia) and President Robert Udelsman called on the society to formally sanction and certify the concept of endocrine surgery training fellowships.8 In 2007, the AAES Fellowship Committee was formed, ably led for 6 years by Dr Allan Siperstein. Also in 2007, the first AAES Fellowship Match was held, and President Christopher R. McHenry petitioned the ACS for an AAES Governor’s position and the American Board of Surgery for a Director position.9 By 2008, there were 16 AAES-recognized fellowships with 24 applicants competing for available positions. In maturing our training, the AAES has carefully scrutinized the parallel evolution of international societies such as the British Association of Endocrine Surgeons and of other US subspecialties, such as surgical oncology which, like endocrine surgery, is based on a systems approach to disease. Surgical oncology, however, has recently gone in a different direction, that of ACGME oversight rather than preserving an independent junior faculty status during fellowship. Interested in the reported correlation of higher hospital and surgeon volumes with good outcomes for many types of surgery, including thyroidectomy, in 2010 Solarzano et al10 reported the results of a survey of endocrine surgeons who had been in practice for 80% of general surgery residents pursue fellowship training without discernibly impacting case volumes for general surgery residents.13 Today our sterling AAES accreditation process is off and running, but as others have said before, in the near future we need to work to have at least one endocrine surgeon on the faculty of each US general surgery residency program. Our fellowships are certainly a reason that endocrine surgeons are increasingly recognized as objective expert caregivers, and in this regard I think we need to move energetically toward formal specialty recognition by both the American Board of Surgery and the American College of Surgeons. I also think we need to include in the fellowship curriculum more specific education about the skills needed to grow one’s practice in the community setting, particularly given the data shown below. And it goes without saying that AAES members need to keep doing their utmost to achieve best outcomes for patients. AAES ENDOCRINE SURGERY UNIVERSITY Genetic hitchhiking occurs when neutral genes are influenced by genes that are under selection.7 Over the last decade or so, Endocrine University has been a popular program held annually by the American Association of Clinical Endocrinologists (AACE) to enhance the training of medical endocrinology
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fellows nationwide. Through the diligent work of Dr Martha A. Zeiger and after careful planning, in 2010 AAES was able to launch, together with AACE, the first annual Endocrine Surgery University (ESU), which was a great success for all attendees---faculty and fellows alike. ESU rapidly became an annual AAES institution. Because the features of this innovative program may not be well known, I will briefly describe them here. ESU is about the art of endocrine surgery as well as the science; the curriculum and format have been gradually adapted to suit the needs of an enlarging and increasingly well-informed pool of fellows. Attendees continue to praise the collegiality, practicality, and good humor of the educational experience. The format is informal and approachable, featuring panel management of real cases and energetic speed-dating–type roundtable discussions with faculty. ESU traditionally culminates in a popular contest based on the TV quiz show Jeopardy, which generates much good fellowship---and fabulous prizes. ESU even has its own logo. In 2013, the AAES decided it was ready to host ESU altogether, so this year I worked along with Dr Zeiger, BSC Management Inc, and the AAES ESU Committee to accomplish that change. The fifth annual ESU was held as a premeeting workshop on April 25 and 26, 2014, including a fireside dinner at Dr Richard A. Hodin’s house, and was again a big success. Last year in Chicago, Dr Quan-Yang Duh had also worked hard to put on a Mock Oral Boards program for the ESU fellows, which we hope to continue in future years. In the approximate words of Isaiah, ‘‘as the rose, shall deserts blossom,’’ and to the dedicated work of Director Zeiger and also to our secretary–treasurers, the AACE, and our several society management companies, AAES owes its deep gratitude for evolving this innovative program. In 2015, Dr Mira M. Milas will be taking over as ESU director and we congratulate her as well. THE AAES QUALITY OUTCOMES INITIATIVE: CESQIP Natural selection occurs only if there is enough variation in a population.7 The AAES Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) is a cloud-based outcomes initiative to maximize patient care in thyroid, parathyroid, adrenal, and pancreatic neuroendocrine operations by permitting benchmarking for the promotion of science, providing for maintenance of certification by the American Board of Surgery, and creating a lattice structure for national and international collaboration. The brainchild of Dr Barry Inabnet, CESQIP was designed to be accessible,
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cost effective, and scientifically valid. It uses sophisticated methods to track outcomes in a realistic, useful way; for example, many parathyroid, thyroid, and adrenal surgeries require specific longterm 6-month follow-up to assess results accurately. CESQIP captures the relevant data, pertinent comorbidities, and indications, and offers real-time dashboard reporting. For individual surgeons, it provides best practice pathways to enhance patient safety, as well as ongoing performance feedback to enable transition to shared accountability models. Users review data privately and can then compare them with the de-identified demographics, practice patterns, outcomes, and resource utilization of other participants. For hospitals, CESQIP meets Meaningful Use and other regulatory requirements like PQRS and MOC Part IV; for patients, best practices will benefit as CESQIP identifies data that influence national performance of endocrine operations. CESQIP was designed to be inclusive and collaborative with enrollment open to all interested surgical specialties, including nonAAES members. The AAES CESQIP committee began work in 2011, and in 2012 President Miguel F. Herrera brought CESQIP to life with development sponsored by the AAES Foundation and several generous patients. Beta testing took place last year as many US programs signed on, along with international sites in Mexico City, Calgary, and Israel. It was natural to select the rhinoceros for CESQIP’s logo, Dr Inabnet explains, not only because it is the animal in which the parathyroid glands were first discovered, but also because it is a highly respected entity, has a calm demeanor, is aggressive only if provoked, and notably nurtures its young. CESQIP data entry takes about 2 minutes per patient and the pathologic and longitudinal data require that the record be entered at least once subsequently. Soon AAES members will vote on recognizing CESQIP as a standing committee in the bylaws. The more surgeons who participate in CESQIP, the more robust are the data and at last update there were a full 24 enrolled institutions with 83 unique users. As Rachel Kaplan says, it is good to engage in activities that shift our consciousness toward an ethic of conservation and care.14 YOU CAN EVOLVE ENDOCRINE SURGERY WITHOUT A PIPETTE Gene flow eventually results in the appearance of new species.7 One of the best things about AAES is that we work actively to improve the field---and this work does not obligate RO1 funding. When I started out, I did do basic science research, but all along my path has been enlivened by the
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knowledge that in endocrine surgery, when you notice something in your clinical practice it is often straightforward to study it productively. Below I give the results of one such study. This year, AAES formed the Community Based Surgeons committee (CBS) to help members have a chance to such research in their own practices. The CBS is chaired by Dr Cory Foster who practices in Ithaca, New York. The committee’s first activity was a survey to find out how many AAES members consider themselves to actually be community endocrine surgeons, which is a relatively new phenomenon. In the past, endocrine surgeons tended to be from academia or another environment conducive to building a practice through years of expertise. Today however, with the increased emphasis on fellowship training, and with HMO computers and hospital employment often directing surgical referrals in the first place,15 a number of our young endocrine surgeons are looking productively at community endocrine surgery jobs. I believe this is a major way that AAES is evolving today. The CBS committee’s survey had interesting results. With a high 62% response rate among active members, a full 37% of respondents said they have or will have a community-based endocrine surgery practice. Also a full 67% of community-based members desire a recognized voice within AAES. Community-based endocrine surgeons value their AAES membership most highly for keeping updated in new techniques, but also for clinical debates and professional networking. Next year, the CBS plans to develop a mission statement and assess in more detail the needs of community-affiliated members. Let’s look briefly at how a simple study can help to evolve practical patient care. We are taught in training that, before operating for apparent sporadic primary hyperparathyroidism, we should ask patients about a family history of multiple endocrine neoplasia (MEN)-1. But even if the patient turns out later to belong to a well-documented kindred, it seems like their answer is invariably ‘‘No.’’ MEN-1 is common in my region of the country and we certainly wondered if there was a better way to uncover it preoperatively, so we instituted prospective use of a simple 6 question panel (6Q). When we tested it for value, the 6Q panel was highly effective compared to family history.16 MEN-1 was increasingly likely with each positive 6Q answer, and also with young age and male sex, which makes sense because MEN-1 is autosomal-dominant, whereas sporadic hyperparathyroidism is much more common in women. Moreover, 22% of patients with false-positive 6Q
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responses actually had jaw–tumor syndrome, which---candidate members---sets you up for doing the next study. This study also answered another longstanding question for me, namely when one finds 4-gland hyperplasia at surgery for presumed sporadic disease, what is the likelihood that the patient has MEN-1; in our region, that chance turned out to be surprisingly high at 1 in 4. The 6 questions for MEN-1 are: Do you have a blood relative with kidney stones, ulcers, brain tumors, pancreatic tumors, high calcium levels, or neck surgery?16 THE AAES GUIDELINES FOR DEFINITIVE TREATMENT OF PRIMARY HYPERPARATHYROIDISM In mutation bias, the change that occurs most often is the one most likely to become retained.7 I clearly recall the day years ago when, scared but determined at our national meeting, and this was before I had ever served on council, I walked up to Dr Jon A. van Heerden, who I had worshipped from afar as omniscient, and said, ‘‘Sir, there’s been so much recent change in the way we do parathyroid surgery, you big guys should talk it over and decide and tell us how to do it.’’ He smiled supportively. As Ursula K. LeGuin says in her luminous novel Always Coming Home, ‘‘human mindfulness begins where the wish to be the same leaves off.’’17 So another lesson here for candidate members is to speak up with your ideas---come and talk with me in the hall any time. After 2 decades of rapid, worldwide innovation in the field of parathyroid surgery, with the aim of cohering best practices for primary hyperparathyroidism, this year the AAES embarked on an exciting new project that will productively define outcome parameters for operative success. The AAES Parathyroidectomy Guidelines brings together multidisciplinary North American experts for an evidence-based, surgeon-sponsored project that is timely, objective, and simply has not been done before. In the past, the proven operative approach for primary hyperparathyroidism has been bilateral exploration under general anesthesia. We use the term ‘‘exploration’’ to address the central anatomic and imaging facts about the disease, which include the realities that about 15% of patients have multiglandular disease, that 10% have >4 parathyroid glands, that imaging tests are notoriously poor at identifying multiglandular disease, and that whether they are normal or enlarged, parathyroid glands can hide all over the neck and upper chest. Thus, although some parathyroid operations can be easily done for
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many other patients experience in dissection is required to find parathyroid glands and decide whether they actually are enlarged before successfully resecting them for cure. Some of the recent pivotal studies evolving the surgery of primary hyperparathyroidism are detailed here. In a far-reaching initiative led by Dr George L. Irvin III, the advent of intraoperative parathormone (IOPTH) monitoring in 199518 stimulated many centers to develop methods for minimally invasive surgery in which routine bilateral dissection was replaced with focused dissection, that is, the surgeon relies on a functional rather than a visual method to assess for abnormal glands.19 At the same time, endocrine surgeons paid closer attention to the objective benefits of successful surgery,20 to the fact of high-volume expertise,21 and to other methods for achieving concise yet successful parathyroidectomy.22-26 The rapid changes also encompassed healthy reexamination of the anatomy,27 imaging,28 indications,29,30 cost efficacy,31 and other controversies.32 Our recent study presented at the Helsinki meeting of the International Association of Endocrine Surgeons, for example, evaluated the criteria used to signal an adequate IOPTH drop and found that operative failure was 19 times more likely if the final level dropped by 50% but not also into the normal range.33 For every surgeon in the field, the desired outcome has always been cure at the first parathyroid operation.34 In Connie Willis’ hilarious novel Bellwether, which dissects the science and morality of fads, her basic science protagonist is asked why after all did she decide to investigate fads source analysis, to which she replies, ‘‘Everybody else was doing it.’’35 So, leaving all fad pressure aside, what are the outcomes of the recent rapid evolution in parathyroid surgical technique? In 2007, Greene et al36 at the Cleveland Clinic surveyed practicing surgeons from AAES and ACS, reporting that minimally invasive parathyroidectomy techniques were increasingly popular but also increasingly disparate. In 2011, I polled the program directors of the 19 AAES fellowship programs, asking what operation was currently taught for sporadic primary hyperparathyroidism without prior neck surgery; candidate members, one lesson here is that it can take a long time for something to appear in print.37 In this study, which had a 100% response rate, the 19 program directors shared many pearls and the findings showed high congruity in surgical management among AAES fellowship programs. A high proportion of programs (84%) routinely check a vitamin D level preoperatively, all obtain at least one imaging study
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to guide exploration, 95% use preoperative ultrasonography to check for concurrent thyroid nodules (which all manage with preoperative fine-needle aspiration biopsy as required), and 68% use some form of oral calcium supplementation postoperatively. Every program defined operative cure by durable eucalcemia, which was measured at a median of 6 months after surgery. There was also high congruity in the way parathyroid surgery is conducted. All programs operate with intent to cure, focus the dissection when anatomically feasible, and convert to a bilateral exploration if required by findings. Other practices, such as nerve monitoring, radioprobe guidance, video-assistance, and routine ipsilateral normal gland biopsy, were relatively uncommon. These congruencies at AAES fellowship programs set a standard for future outcomes analysis in parathyroid surgery. The AAES Parathyroidectomy Guidelines will not be proscriptive, but instead will be inclusive of the several successful ways to accomplish initial parathyroid surgery for cure. The multidisciplinary writing group is broad-based and the Methods are the standard peer-reviewed ones used, for example, by the American Thyroid Association in their influential Guidelines for Thyroid Nodule and Thyroid Cancer Management.38 Controversy is often healthy, and several of the more topical subjects include the indications for parathyroid surgery, the cost efficacy of surgery versus observation, the use of techniques and adjuncts validated to achieve cure, concurrent thyroidectomy, and the definitions of postoperative cure and failure. I am excited that the AAES is able to work on this important data-driven project and I encourage members to contribute their thoughts to strengthen and evolve the field of endocrine surgery. I also think this is just a start for the AAES, and in evolving its mission further, our association may want to consider doing other types of surgical guidelines in future. INTERPERSONAL EVOLUTION Genetic drift occurs when selective forces are absent or slight, as when a small population becomes segregated.7 Today, the very existence of evolution is still contested by some groups in the United States. In my direct experience, being a female surgeon has also been contested by some groups, sometimes even today. At present over half the US population is female, half of medical students are women, and more than one third of surgery residents are women, but we still face challenges in some professional and social settings. Unlike the process of
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Fig 1. AAES membership by year since the society was founded in 1980. Hashed bars, Total membership; solid bars, total female membership; solid line, percent of members who are women.
genetic drift, the AAES has evolved to be famously egalitarian and fair to diverse kinds of surgeons. In fact in my experience---without comment, without resistance, and with notable grace---the AAES has been a real haven to women in surgery. AAES membership has rapidly increased since its founding in 1980, especially recently. In addition (as shown from the numbers that I could pull personally since 1990), the number of female AAES members is also increasing (Fig 1). At the 1991 meeting held in San Jose California, the 4 women listed in the program book included Dr Maria D. Allo, Dr Barbara K. Kinder (who was our first female President), and Dr Patricia J. Numann (who last year was President of the American College of Surgeons). The fact that they existed, not to mention were friendly and competent surgeons, has been a huge boon to me personally and professionally. Of further interest is the rising proportion of women surgeons in the AAES, increasing by #14% by 2011 and today even higher at 23.4% (Fig 1). The societal evolution of the surgical world that has been provoked in the United States by the reforms of the 80-hour workweek, and by other reforms, is not over yet. In the modern era even Star Trek has changed its tune; in the 2009 film, the famous closing byline is now, ‘‘Where No One has Gone Before.’’39 And as the AAES continues to expand, we are learning to welcome new colleagues. For example, we will vote soon on a popular and timely amendment to admit nonphysician health providers to AAES membership. Evolution can be personal. I started out in science under the tutelage of the wonderful and egalitarian Dr Antonio Scarpa in the Department of Biophysics and Bioenergetics at the University of Pennsylvania. Later Toni went on to become
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Fig 2. The Carty–Schaitkin household, circa 2004. From left: Hope, Simon (standing), Barry, Sally, and Iris.
Director for Scientific Review at the National Institutes of Health, but when he hired me in 1978 as a clueless lab tech right out of college, little did I realize it was the start of my life in endocrinology and surgery. Led by the excellent Dr Robert G. Johnson, it was my job to pick up the adrenal glands from a slaughterhouse north of Philly, prepare the chromaffin granules and ghosts, do the experiments, and, later, supervise others to do the same. This work established the fascinating facts that APUD neuroendocrine secretory granules have a transmembrane protontranslocating ATPase that generates an electrochemical proton gradient (inside acidic and inside positive) to drive biogenic amine storage by APUD organelles, in other words chromaffin granules are inside out mitochondria.40 With that foothold in endocrine research, after residency the natural next step was surgical oncology fellowship at the National Cancer Institute (NCI) with Dr Jeffrey A. Norton and Dr Steve A. Rosenberg. Many other AAES members have also trained at the NCI. I then joined the faculty at University of Pittsburgh in 1991 with a basic science research effort in bioballistic viral interleukin-10 gene transfer in murine islet xenografts, but in later years I moved on to other compelling research projects (Fig 2), the outcomes of which are promising, but still in evolution. Over the last decade it has been my privilege to help advance the field of molecular profiling for thyroid nodules and thyroid cancer, which you’ve heard about at this meeting from my superb colleague Dr Yuri E. Nikiforov. Some of the many others at Pitt who have guided and helped
me professionally are Dr Richard L. Simmons, Dr David L. Bartlett, Dr Marshall W. Webster, Dr Timothy R. Billiar, Dr Charles G. Watson, and Dr Barry M. Schaitkin, and I thank each of them wholeheartedly. I also thank my truly wonderful partners Dr Linwah Yip, Dr Michael T. Stang, Dr Kelly M. McCoy, and Dr Michaele J. Armstrong, my office staff including Ms. Carol A. Bykowski and Ms. Lisa Lafay, and my friends Dr Nancy D. Perrier, Dr Herbert Chen, and Ms. Adeena M. Bleich, all of whom have graciously helped me laugh and cope. In particular, my husband Dr Barry M. Schaitkin, is the best friend, humorist, and physician in the world, and I thank him deeply. Being AAES President has been the honor and highlight of my career. I am so grateful for the experience, personally as well as professionally. I thank you each very much. The AAES mission statement says that the AAES is ‘‘dedicated to the advancement of the science and art of endocrine surgery and maintenance of high standards in the practice of endocrine surgery.’’ Our societal evolution requires thought, care, balance, and personal commitment. Each of our members has chosen a specialty that notably progresses, one that prizes evolution on behalf of its patients, and one that follows its words with cheerful, competent, ethical action. You can add to that, yourself. I would like you to thank each other. REFERENCES 1. Wang TS. Endocrine Surgery. Am J Surg 2011;202:369-71. 2. Welbourn RB. The history of endocrine surgery. New York: Praeger; 1990. 3. Pasieka JL. Kindred spirits of the endocrines: the training of future endocrine surgeons. J Surg Oncol 2005;89:202-5. 4. Prinz RA. Endocrine surgical training–some ABC measures. Surgery 1996;120:905-12. 5. Thompson NW. The founding of the American Association of Endocrine Surgeons: the time was right. Surgery 2011; 150:1303-7. 6. Heinlein RA. The moon is a harsh mistress. New York: G.P. Putnam’s Sons; 1965/1994. 7. Wikipedia. Evolution. Available from: http://en.wikipedia/ org/wiki/Evolution. 8. American Association of Endocrine Surgeons (AAES). AAES News [cited 2005 Nov]. Available from: endocrinesurgery. org. 9. American Association of Endocrine Surgeons (AAES). AAES News [cited 2007 Jan]. Available from: endocrinesurgery. org. 10. Solarzano CC, Sosa JA, Lechner SC, Lew JI, Roman SA. Endocrine surgery: where are we today? A national survey of young endocrine surgeons. Surgery 2010;147:536-41. 11. Tsinberg M, Duh QY, Cisco RM, Gosnell JE, Scholten A, Clark OH, et al. Practice patterns and job satisfaction in fellowshiptrained endocrine surgeons. Surgery 2012;152:953-6. 12. Shin JJ, Milas M, Mitchell J, Berber E, Gutnick J, Siperstein A. The endocrine surgery job market: as survey of fellows,
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department chairs, and surgery recruiters. J Surg Educ 2013;7:377-83. Hanks JB, Ashley SW, Mahvi DM, Meredith WJ, Stain SC, Biester TW, et al. Feast or famine? The variable impact of coexisting fellowships on general surgery resident operative volumes. Ann Surg 2011;254:476-83. Kaplan R, Blume KR. Urban homesteading: heirloom skills for sustainable living. New York: Skyhorse Publishing Inc; 2011. Charles AG, Ortiz-Pujols S, Ricketts T, Fraher E, Neuwahl S, Cairnes B, et al. The employed surgeon: a changing professional paradigm. JAMA Surg 2013;148:323-8. Yip L, Ogilvie JB, Challinor SB, Salata RA, Thull DL, Yim JH, et al. Identification of multiple endocrine neoplasia type 1 in patients with apparent sporadic primary hyperparathyroidism. Surgery 2008;144:1002-7. LeGuin UK. Always coming home. New York: Harper and Row; 1985. Sfakianakis GN, Irvin GL III, Foss J, Mallin W, Georgiou M, Deriso GT, et al. Efficient parathyroidectomy guided by SPECT-MIBI and hormonal measurements. J Nucl Med 1996;37:798-804. Miccoli P, Pinchera A, Cecchini G, Conte M, Bendinelli C, Vignali E, et al. Minimally invasive, video-assisted parathyroid surgery for primary hyperparathyroidism. J Endocrinol Invest 1997;20:429-30. Pasieka JL, Parsons LL. Prospective surgical outcome study of relief of symptoms in patients with primary hyperparathyroidism. World J Surg 1998;22:513-9. Sosa JA, Powe NR, Levine MA, Udelsman R, Zeiger MA. Profile of a clinical practice: thresholds for surgery and surgical outcomes for patients with primary hyperparathyroidism: a national survey of endocrine surgeons. J Clin Endocrinol Metab 1998;83:2658-65. Carty SE, Worsey J, Virji MA, Brown ML, Watson CG. Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay. Surgery 1997;122:1107-14; discussion 1114-6. Norman JG, Jaffray CE, Chheda H. The false-positive parathyroid sestamibi: a real or perceived problem and a case for radioguided parathyroidectomy. Ann Surg 1997;231:31-7. Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery 1999;126:1016-21. Henry JF, Iacobone M, Mirallie E, Deveze A, Pili S. Indications and results of video-assisted parathyroidectomy by a lateral approach in patients with primary hyperparathyroidism. Surgery 2001;130:999-1004.
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26. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 2002; 235:665-72. 27. Yip L, Pryma DA, Yim JH, Virji MA, Carty SE, Ogilvie JB. Can a lightbulb sestamibi SPECT accurately predict single-gland disease in sporadic primary hyperparathyroidism? World J Surg 2008;32:784-92. 28. Javiev AA, Lew JI, Solarzano CC. Surgeon-performed ultrasound: a single institution experience in parathyroid localization. Surgery 2009;146:569-75. 29. Mihai R, Sadler GP. Pasieka’s parathyroid symptoms scores correlate with SF-36 scores in patients undergoing surgery for primary hyperparathyroidism. World J Surg 2008;32: 807-14. 30. Perrier ND, Balachandran D, Wefel JS, Jimenez C, Busaidy N, Morris GS, et al. Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with ‘‘asymptomatic’’ primary hyperparathyroidism. Surgery 2009;146:1116-22. 31. Zanocco K, Heller M, Sturgeon C. Cost-effectiveness of parathyroidectomy for primary hyperparathyroidism. Endocr Pract 2011;17(Suppl 1):69-74. 32. Schneider DF, Mazeh H, Sippel RS, Chen H. Is minimally invasive parathyroidectomy associated with greater recurrence compared to bilateral exploration? Analysis of more than 1,000 cases. Surgery 2012;152:1008-15. 33. Wharry LI, Yip L, Armstrong MJ, Virji MA, Stang MT, Carty SE, et al. The final intraoperative parathyroid hormone level: how low should it go? World J Surg 2014;38:558-63. 34. Doherty GM, Weber B, Norton JA. Cost of unsuccessful surgery for primary hyperparathyroidism. Surgery 1994;116: 954-7. 35. Willis C. Bellwether. New York: Bantam Books; 1996. 36. Greene AM, Butler RS, McIntyre S, Barbosa GF, Mitchell J, Berber E, et al. National trends in parathyroid surgery from 1998 to 2008: a decade of change. J Am Coll Surg 2009;209: 332-43. 37. Wang TS, Pasieka JP, Carty SE. Techniques of parathyroid exploration at North American Endocrine Surgery Fellowship Programs: what the next generation is being taught. Am J Surg 2014;207:527-32. 38. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19:1-48. 39. Star Trek. Los Angeles: Paramount Pictures; 2009. 40. Johnson RG, Carty SE, Scarpa A. Proton: substrate stoichiometries during active transport of biogenic amines in chromaffin ghosts. J Biol Chem 1981;256:5773-80.
From the University of Pittsburgh, Pittsburgh, PA
EVOLUTION IT IS A GREAT PRIVILEGE to address this superb 2014 meeting of the American Association of Endocrine Surgeons. Once again we have record-breaking attendance. In the beginning, were the Bylaws. I’ve been told that this Presidential Address should be about what is important to me, while reflecting the mission of our society and what is important to its members. This address is therefore, about your society, the American Association of Endocrine Surgeons (AAES). To me, transparency is also important and as AAES becomes larger and more complex, we want to keep all members productively in the loop. Thus, interspersed with some personal wisdom, in this article I provide you with state-of-the-union exposition of some of the important initiatives for which an army of people have cheerfully done huge amounts of volunteer work this year as the AAES evolves into the vibrant, intelligent, busy society of today and tomorrow. And because this year’s theme was education, I will also give some concrete suggestions to our AAES candidate members. Endocrine surgery is a relatively new specialty. Its identity is driven in large part by the increasing complexity of today’s management of surgical disorders of the thyroid, parathyroid, adrenal glands, and neuroendocrine pancreas.1 In the Accepted for publication August 21, 2014. Reprint requests: Sally E. Carty, MD, FACS, University of Pittsburgh, Pittsburgh, PA. E-mail: [email protected]. Surgery 2014;156:1289-96. 0039-6060/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.08.072
past, these diseases were incompletely understood, and even today are often missed. Endocrine Surgery has actually been practiced for over a century, as summarized from the works of Dr Richard B. Welbourn and Dr Janice L. Pasieka.2,3 In the 19th century, there was resection of endocrine glands for enlargement and neoplasia; at the turn of the century, as hormones were discovered, there was surgery for hypersecretory states; and in 1948 the release of cortisone for medical use allowed safe adrenalectomy. Next, surgeons like Dr Oliver Cope began to focus on the physiologic responses of surgical manipulation of a diseased organ while the APUDoma concept also took hold. By the time of Dr Richard A. Prinz’s Presidential Address in 1996, there were 70 approved US residency programs in general surgery that had at least one endocrine surgeon on faculty.4 More recently, the AAES has developed curricula for residency training in general surgery and for fellowship training in endocrine surgery, as you will see in more detail below. The AAES was founded in 1980, with the bylaws initially drafted by Dr Jay Harness,5 and our beloved Dr Norman W. Thompson was the inaugural president of the AAES. But by 1990, when I began going to meetings as a fellow in the Surgery Branch of the National Cancer Institute, it was basically still a club---of smart, nice egalitarian people in a surgical world that at that time was unfortunately not always nice. Today however, endocrine surgery is a rapidly growing specialty with a unique personality, a personality that is due in large part to the responsible, generous natures of many prior ‘‘greats,’’ some of whom I will mention below, and others of whom include Dr Timothy S. Harrison, Dr Edwin L. Kaplan, Dr Orlo H. Clark, Dr Paolo Miccoli, SURGERY 1289
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Dr Jean-Francois Henry, Dr Stuart D. Wilson, Dr Bertil Hamberger, Dr Per-Ola Granberg, Dr Colin F. J. Russell, and Dr Janice L. Pasieka. These true gentlepeople have been and are my role models, and I thank each of them very kindly. In full disclosure, right from the beginning the AAES has been unlike other professional surgical societies, being characterized by a particular brand of friendly, creative curiosity and by a strong interest in best results for patients. To perhaps overstate it, while it is true that endocrine surgeons are smart, detail-oriented nerds who love to talk shop, we also embrace change easily and we work notably hard to prospectively and objectively advance the field. We love to use complicated tumor markers, perform delicate surgeries, and invent intricate management algorithms, but we also prize clever, directly practical care. Endocrine surgeons also stand out for the habit of reflection, a true joy in mentoring, and a bias toward collaboration, which is often multidisciplinary in nature. An obvious example of the collective spirit was the work of Dr Geoffrey B. Thompson, culminating in the 2008 vote to admit our allied surgical colleagues to membership. AAES members are also enthusiastic volunteers, as our new administration company BSC Management Inc is learning: ‘‘OK how about we do a trip to the Moon! Great idea! Is it feasible, and who else wants to work on it?’’ Energy is our heritage, but no matter how much we wish to take on for patients we also consider that, as Robert A. Heinlein said in his marvelous novel The Moon is a Harsh Mistress, ‘‘there ain’t no such thing as a free lunch.’’6 As I detail the AAES9 evolving initiatives, it will be good to keep in mind that dictionaries variously defines evolution as (1) the process by which living organisms are thought to have developed and diversified from earlier forms during the history of the earth and (2) the gradual development of something, especially from a simple to a more complex form. Wikipedia Inc, which today has replaced the oracle at Delphi---in fact during thyroidectomy, we should call it the Wikipedian lymph node---lists the mechanisms of evolution that we all recall so clearly from medical school as: Natural selection, mutation bias, genetic drift, genetic hitchhiking, and gene flow.7 And because the AAES is all about outcomes, let’s also keep in mind the potential outcomes of evolution, which are adaptation, coevolution, cooperation, speciation, and extinction. A BRIEF HISTORY OF AAES FELLOWSHIP TRAINING Evolution is gradual development from a simple to a more complex form. In the words of Dr Tracy S.
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Wang, as medicine evolves, the perioperative management of patients with hormone-secreting tumors has become increasingly intricate and refined.1 At the same time, endocrine surgical care has also become more centralized to those with best outcomes, leading to a higher standard of care that Dr Pasieka in 2009 described as a classic positive feedback loop: ‘‘A higher standard of care in focus areas stimulates research, and research in turn improves the quality of education and training. which leads to better patient care.’’3 In 1996, Dr Prinz called for the AAES to develop defined educational goals and objectives for the extant apprentice-type postgraduate training available in endocrine surgery.4 This call has since been refined and extended by a number of our leaders. In 2005, the AAES Education and Research Committee developed a formal curriculum for fellowship training. That year there were 11 fellowships listed on our website (9 in the United States and 1 each in Canada and Australia) and President Robert Udelsman called on the society to formally sanction and certify the concept of endocrine surgery training fellowships.8 In 2007, the AAES Fellowship Committee was formed, ably led for 6 years by Dr Allan Siperstein. Also in 2007, the first AAES Fellowship Match was held, and President Christopher R. McHenry petitioned the ACS for an AAES Governor’s position and the American Board of Surgery for a Director position.9 By 2008, there were 16 AAES-recognized fellowships with 24 applicants competing for available positions. In maturing our training, the AAES has carefully scrutinized the parallel evolution of international societies such as the British Association of Endocrine Surgeons and of other US subspecialties, such as surgical oncology which, like endocrine surgery, is based on a systems approach to disease. Surgical oncology, however, has recently gone in a different direction, that of ACGME oversight rather than preserving an independent junior faculty status during fellowship. Interested in the reported correlation of higher hospital and surgeon volumes with good outcomes for many types of surgery, including thyroidectomy, in 2010 Solarzano et al10 reported the results of a survey of endocrine surgeons who had been in practice for 80% of general surgery residents pursue fellowship training without discernibly impacting case volumes for general surgery residents.13 Today our sterling AAES accreditation process is off and running, but as others have said before, in the near future we need to work to have at least one endocrine surgeon on the faculty of each US general surgery residency program. Our fellowships are certainly a reason that endocrine surgeons are increasingly recognized as objective expert caregivers, and in this regard I think we need to move energetically toward formal specialty recognition by both the American Board of Surgery and the American College of Surgeons. I also think we need to include in the fellowship curriculum more specific education about the skills needed to grow one’s practice in the community setting, particularly given the data shown below. And it goes without saying that AAES members need to keep doing their utmost to achieve best outcomes for patients. AAES ENDOCRINE SURGERY UNIVERSITY Genetic hitchhiking occurs when neutral genes are influenced by genes that are under selection.7 Over the last decade or so, Endocrine University has been a popular program held annually by the American Association of Clinical Endocrinologists (AACE) to enhance the training of medical endocrinology
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fellows nationwide. Through the diligent work of Dr Martha A. Zeiger and after careful planning, in 2010 AAES was able to launch, together with AACE, the first annual Endocrine Surgery University (ESU), which was a great success for all attendees---faculty and fellows alike. ESU rapidly became an annual AAES institution. Because the features of this innovative program may not be well known, I will briefly describe them here. ESU is about the art of endocrine surgery as well as the science; the curriculum and format have been gradually adapted to suit the needs of an enlarging and increasingly well-informed pool of fellows. Attendees continue to praise the collegiality, practicality, and good humor of the educational experience. The format is informal and approachable, featuring panel management of real cases and energetic speed-dating–type roundtable discussions with faculty. ESU traditionally culminates in a popular contest based on the TV quiz show Jeopardy, which generates much good fellowship---and fabulous prizes. ESU even has its own logo. In 2013, the AAES decided it was ready to host ESU altogether, so this year I worked along with Dr Zeiger, BSC Management Inc, and the AAES ESU Committee to accomplish that change. The fifth annual ESU was held as a premeeting workshop on April 25 and 26, 2014, including a fireside dinner at Dr Richard A. Hodin’s house, and was again a big success. Last year in Chicago, Dr Quan-Yang Duh had also worked hard to put on a Mock Oral Boards program for the ESU fellows, which we hope to continue in future years. In the approximate words of Isaiah, ‘‘as the rose, shall deserts blossom,’’ and to the dedicated work of Director Zeiger and also to our secretary–treasurers, the AACE, and our several society management companies, AAES owes its deep gratitude for evolving this innovative program. In 2015, Dr Mira M. Milas will be taking over as ESU director and we congratulate her as well. THE AAES QUALITY OUTCOMES INITIATIVE: CESQIP Natural selection occurs only if there is enough variation in a population.7 The AAES Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) is a cloud-based outcomes initiative to maximize patient care in thyroid, parathyroid, adrenal, and pancreatic neuroendocrine operations by permitting benchmarking for the promotion of science, providing for maintenance of certification by the American Board of Surgery, and creating a lattice structure for national and international collaboration. The brainchild of Dr Barry Inabnet, CESQIP was designed to be accessible,
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cost effective, and scientifically valid. It uses sophisticated methods to track outcomes in a realistic, useful way; for example, many parathyroid, thyroid, and adrenal surgeries require specific longterm 6-month follow-up to assess results accurately. CESQIP captures the relevant data, pertinent comorbidities, and indications, and offers real-time dashboard reporting. For individual surgeons, it provides best practice pathways to enhance patient safety, as well as ongoing performance feedback to enable transition to shared accountability models. Users review data privately and can then compare them with the de-identified demographics, practice patterns, outcomes, and resource utilization of other participants. For hospitals, CESQIP meets Meaningful Use and other regulatory requirements like PQRS and MOC Part IV; for patients, best practices will benefit as CESQIP identifies data that influence national performance of endocrine operations. CESQIP was designed to be inclusive and collaborative with enrollment open to all interested surgical specialties, including nonAAES members. The AAES CESQIP committee began work in 2011, and in 2012 President Miguel F. Herrera brought CESQIP to life with development sponsored by the AAES Foundation and several generous patients. Beta testing took place last year as many US programs signed on, along with international sites in Mexico City, Calgary, and Israel. It was natural to select the rhinoceros for CESQIP’s logo, Dr Inabnet explains, not only because it is the animal in which the parathyroid glands were first discovered, but also because it is a highly respected entity, has a calm demeanor, is aggressive only if provoked, and notably nurtures its young. CESQIP data entry takes about 2 minutes per patient and the pathologic and longitudinal data require that the record be entered at least once subsequently. Soon AAES members will vote on recognizing CESQIP as a standing committee in the bylaws. The more surgeons who participate in CESQIP, the more robust are the data and at last update there were a full 24 enrolled institutions with 83 unique users. As Rachel Kaplan says, it is good to engage in activities that shift our consciousness toward an ethic of conservation and care.14 YOU CAN EVOLVE ENDOCRINE SURGERY WITHOUT A PIPETTE Gene flow eventually results in the appearance of new species.7 One of the best things about AAES is that we work actively to improve the field---and this work does not obligate RO1 funding. When I started out, I did do basic science research, but all along my path has been enlivened by the
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knowledge that in endocrine surgery, when you notice something in your clinical practice it is often straightforward to study it productively. Below I give the results of one such study. This year, AAES formed the Community Based Surgeons committee (CBS) to help members have a chance to such research in their own practices. The CBS is chaired by Dr Cory Foster who practices in Ithaca, New York. The committee’s first activity was a survey to find out how many AAES members consider themselves to actually be community endocrine surgeons, which is a relatively new phenomenon. In the past, endocrine surgeons tended to be from academia or another environment conducive to building a practice through years of expertise. Today however, with the increased emphasis on fellowship training, and with HMO computers and hospital employment often directing surgical referrals in the first place,15 a number of our young endocrine surgeons are looking productively at community endocrine surgery jobs. I believe this is a major way that AAES is evolving today. The CBS committee’s survey had interesting results. With a high 62% response rate among active members, a full 37% of respondents said they have or will have a community-based endocrine surgery practice. Also a full 67% of community-based members desire a recognized voice within AAES. Community-based endocrine surgeons value their AAES membership most highly for keeping updated in new techniques, but also for clinical debates and professional networking. Next year, the CBS plans to develop a mission statement and assess in more detail the needs of community-affiliated members. Let’s look briefly at how a simple study can help to evolve practical patient care. We are taught in training that, before operating for apparent sporadic primary hyperparathyroidism, we should ask patients about a family history of multiple endocrine neoplasia (MEN)-1. But even if the patient turns out later to belong to a well-documented kindred, it seems like their answer is invariably ‘‘No.’’ MEN-1 is common in my region of the country and we certainly wondered if there was a better way to uncover it preoperatively, so we instituted prospective use of a simple 6 question panel (6Q). When we tested it for value, the 6Q panel was highly effective compared to family history.16 MEN-1 was increasingly likely with each positive 6Q answer, and also with young age and male sex, which makes sense because MEN-1 is autosomal-dominant, whereas sporadic hyperparathyroidism is much more common in women. Moreover, 22% of patients with false-positive 6Q
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responses actually had jaw–tumor syndrome, which---candidate members---sets you up for doing the next study. This study also answered another longstanding question for me, namely when one finds 4-gland hyperplasia at surgery for presumed sporadic disease, what is the likelihood that the patient has MEN-1; in our region, that chance turned out to be surprisingly high at 1 in 4. The 6 questions for MEN-1 are: Do you have a blood relative with kidney stones, ulcers, brain tumors, pancreatic tumors, high calcium levels, or neck surgery?16 THE AAES GUIDELINES FOR DEFINITIVE TREATMENT OF PRIMARY HYPERPARATHYROIDISM In mutation bias, the change that occurs most often is the one most likely to become retained.7 I clearly recall the day years ago when, scared but determined at our national meeting, and this was before I had ever served on council, I walked up to Dr Jon A. van Heerden, who I had worshipped from afar as omniscient, and said, ‘‘Sir, there’s been so much recent change in the way we do parathyroid surgery, you big guys should talk it over and decide and tell us how to do it.’’ He smiled supportively. As Ursula K. LeGuin says in her luminous novel Always Coming Home, ‘‘human mindfulness begins where the wish to be the same leaves off.’’17 So another lesson here for candidate members is to speak up with your ideas---come and talk with me in the hall any time. After 2 decades of rapid, worldwide innovation in the field of parathyroid surgery, with the aim of cohering best practices for primary hyperparathyroidism, this year the AAES embarked on an exciting new project that will productively define outcome parameters for operative success. The AAES Parathyroidectomy Guidelines brings together multidisciplinary North American experts for an evidence-based, surgeon-sponsored project that is timely, objective, and simply has not been done before. In the past, the proven operative approach for primary hyperparathyroidism has been bilateral exploration under general anesthesia. We use the term ‘‘exploration’’ to address the central anatomic and imaging facts about the disease, which include the realities that about 15% of patients have multiglandular disease, that 10% have >4 parathyroid glands, that imaging tests are notoriously poor at identifying multiglandular disease, and that whether they are normal or enlarged, parathyroid glands can hide all over the neck and upper chest. Thus, although some parathyroid operations can be easily done for
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many other patients experience in dissection is required to find parathyroid glands and decide whether they actually are enlarged before successfully resecting them for cure. Some of the recent pivotal studies evolving the surgery of primary hyperparathyroidism are detailed here. In a far-reaching initiative led by Dr George L. Irvin III, the advent of intraoperative parathormone (IOPTH) monitoring in 199518 stimulated many centers to develop methods for minimally invasive surgery in which routine bilateral dissection was replaced with focused dissection, that is, the surgeon relies on a functional rather than a visual method to assess for abnormal glands.19 At the same time, endocrine surgeons paid closer attention to the objective benefits of successful surgery,20 to the fact of high-volume expertise,21 and to other methods for achieving concise yet successful parathyroidectomy.22-26 The rapid changes also encompassed healthy reexamination of the anatomy,27 imaging,28 indications,29,30 cost efficacy,31 and other controversies.32 Our recent study presented at the Helsinki meeting of the International Association of Endocrine Surgeons, for example, evaluated the criteria used to signal an adequate IOPTH drop and found that operative failure was 19 times more likely if the final level dropped by 50% but not also into the normal range.33 For every surgeon in the field, the desired outcome has always been cure at the first parathyroid operation.34 In Connie Willis’ hilarious novel Bellwether, which dissects the science and morality of fads, her basic science protagonist is asked why after all did she decide to investigate fads source analysis, to which she replies, ‘‘Everybody else was doing it.’’35 So, leaving all fad pressure aside, what are the outcomes of the recent rapid evolution in parathyroid surgical technique? In 2007, Greene et al36 at the Cleveland Clinic surveyed practicing surgeons from AAES and ACS, reporting that minimally invasive parathyroidectomy techniques were increasingly popular but also increasingly disparate. In 2011, I polled the program directors of the 19 AAES fellowship programs, asking what operation was currently taught for sporadic primary hyperparathyroidism without prior neck surgery; candidate members, one lesson here is that it can take a long time for something to appear in print.37 In this study, which had a 100% response rate, the 19 program directors shared many pearls and the findings showed high congruity in surgical management among AAES fellowship programs. A high proportion of programs (84%) routinely check a vitamin D level preoperatively, all obtain at least one imaging study
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to guide exploration, 95% use preoperative ultrasonography to check for concurrent thyroid nodules (which all manage with preoperative fine-needle aspiration biopsy as required), and 68% use some form of oral calcium supplementation postoperatively. Every program defined operative cure by durable eucalcemia, which was measured at a median of 6 months after surgery. There was also high congruity in the way parathyroid surgery is conducted. All programs operate with intent to cure, focus the dissection when anatomically feasible, and convert to a bilateral exploration if required by findings. Other practices, such as nerve monitoring, radioprobe guidance, video-assistance, and routine ipsilateral normal gland biopsy, were relatively uncommon. These congruencies at AAES fellowship programs set a standard for future outcomes analysis in parathyroid surgery. The AAES Parathyroidectomy Guidelines will not be proscriptive, but instead will be inclusive of the several successful ways to accomplish initial parathyroid surgery for cure. The multidisciplinary writing group is broad-based and the Methods are the standard peer-reviewed ones used, for example, by the American Thyroid Association in their influential Guidelines for Thyroid Nodule and Thyroid Cancer Management.38 Controversy is often healthy, and several of the more topical subjects include the indications for parathyroid surgery, the cost efficacy of surgery versus observation, the use of techniques and adjuncts validated to achieve cure, concurrent thyroidectomy, and the definitions of postoperative cure and failure. I am excited that the AAES is able to work on this important data-driven project and I encourage members to contribute their thoughts to strengthen and evolve the field of endocrine surgery. I also think this is just a start for the AAES, and in evolving its mission further, our association may want to consider doing other types of surgical guidelines in future. INTERPERSONAL EVOLUTION Genetic drift occurs when selective forces are absent or slight, as when a small population becomes segregated.7 Today, the very existence of evolution is still contested by some groups in the United States. In my direct experience, being a female surgeon has also been contested by some groups, sometimes even today. At present over half the US population is female, half of medical students are women, and more than one third of surgery residents are women, but we still face challenges in some professional and social settings. Unlike the process of
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Fig 1. AAES membership by year since the society was founded in 1980. Hashed bars, Total membership; solid bars, total female membership; solid line, percent of members who are women.
genetic drift, the AAES has evolved to be famously egalitarian and fair to diverse kinds of surgeons. In fact in my experience---without comment, without resistance, and with notable grace---the AAES has been a real haven to women in surgery. AAES membership has rapidly increased since its founding in 1980, especially recently. In addition (as shown from the numbers that I could pull personally since 1990), the number of female AAES members is also increasing (Fig 1). At the 1991 meeting held in San Jose California, the 4 women listed in the program book included Dr Maria D. Allo, Dr Barbara K. Kinder (who was our first female President), and Dr Patricia J. Numann (who last year was President of the American College of Surgeons). The fact that they existed, not to mention were friendly and competent surgeons, has been a huge boon to me personally and professionally. Of further interest is the rising proportion of women surgeons in the AAES, increasing by #14% by 2011 and today even higher at 23.4% (Fig 1). The societal evolution of the surgical world that has been provoked in the United States by the reforms of the 80-hour workweek, and by other reforms, is not over yet. In the modern era even Star Trek has changed its tune; in the 2009 film, the famous closing byline is now, ‘‘Where No One has Gone Before.’’39 And as the AAES continues to expand, we are learning to welcome new colleagues. For example, we will vote soon on a popular and timely amendment to admit nonphysician health providers to AAES membership. Evolution can be personal. I started out in science under the tutelage of the wonderful and egalitarian Dr Antonio Scarpa in the Department of Biophysics and Bioenergetics at the University of Pennsylvania. Later Toni went on to become
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Fig 2. The Carty–Schaitkin household, circa 2004. From left: Hope, Simon (standing), Barry, Sally, and Iris.
Director for Scientific Review at the National Institutes of Health, but when he hired me in 1978 as a clueless lab tech right out of college, little did I realize it was the start of my life in endocrinology and surgery. Led by the excellent Dr Robert G. Johnson, it was my job to pick up the adrenal glands from a slaughterhouse north of Philly, prepare the chromaffin granules and ghosts, do the experiments, and, later, supervise others to do the same. This work established the fascinating facts that APUD neuroendocrine secretory granules have a transmembrane protontranslocating ATPase that generates an electrochemical proton gradient (inside acidic and inside positive) to drive biogenic amine storage by APUD organelles, in other words chromaffin granules are inside out mitochondria.40 With that foothold in endocrine research, after residency the natural next step was surgical oncology fellowship at the National Cancer Institute (NCI) with Dr Jeffrey A. Norton and Dr Steve A. Rosenberg. Many other AAES members have also trained at the NCI. I then joined the faculty at University of Pittsburgh in 1991 with a basic science research effort in bioballistic viral interleukin-10 gene transfer in murine islet xenografts, but in later years I moved on to other compelling research projects (Fig 2), the outcomes of which are promising, but still in evolution. Over the last decade it has been my privilege to help advance the field of molecular profiling for thyroid nodules and thyroid cancer, which you’ve heard about at this meeting from my superb colleague Dr Yuri E. Nikiforov. Some of the many others at Pitt who have guided and helped
me professionally are Dr Richard L. Simmons, Dr David L. Bartlett, Dr Marshall W. Webster, Dr Timothy R. Billiar, Dr Charles G. Watson, and Dr Barry M. Schaitkin, and I thank each of them wholeheartedly. I also thank my truly wonderful partners Dr Linwah Yip, Dr Michael T. Stang, Dr Kelly M. McCoy, and Dr Michaele J. Armstrong, my office staff including Ms. Carol A. Bykowski and Ms. Lisa Lafay, and my friends Dr Nancy D. Perrier, Dr Herbert Chen, and Ms. Adeena M. Bleich, all of whom have graciously helped me laugh and cope. In particular, my husband Dr Barry M. Schaitkin, is the best friend, humorist, and physician in the world, and I thank him deeply. Being AAES President has been the honor and highlight of my career. I am so grateful for the experience, personally as well as professionally. I thank you each very much. The AAES mission statement says that the AAES is ‘‘dedicated to the advancement of the science and art of endocrine surgery and maintenance of high standards in the practice of endocrine surgery.’’ Our societal evolution requires thought, care, balance, and personal commitment. Each of our members has chosen a specialty that notably progresses, one that prizes evolution on behalf of its patients, and one that follows its words with cheerful, competent, ethical action. You can add to that, yourself. I would like you to thank each other. REFERENCES 1. Wang TS. Endocrine Surgery. Am J Surg 2011;202:369-71. 2. Welbourn RB. The history of endocrine surgery. New York: Praeger; 1990. 3. Pasieka JL. Kindred spirits of the endocrines: the training of future endocrine surgeons. J Surg Oncol 2005;89:202-5. 4. Prinz RA. Endocrine surgical training–some ABC measures. Surgery 1996;120:905-12. 5. Thompson NW. The founding of the American Association of Endocrine Surgeons: the time was right. Surgery 2011; 150:1303-7. 6. Heinlein RA. The moon is a harsh mistress. New York: G.P. Putnam’s Sons; 1965/1994. 7. Wikipedia. Evolution. Available from: http://en.wikipedia/ org/wiki/Evolution. 8. American Association of Endocrine Surgeons (AAES). AAES News [cited 2005 Nov]. Available from: endocrinesurgery. org. 9. American Association of Endocrine Surgeons (AAES). AAES News [cited 2007 Jan]. Available from: endocrinesurgery. org. 10. Solarzano CC, Sosa JA, Lechner SC, Lew JI, Roman SA. Endocrine surgery: where are we today? A national survey of young endocrine surgeons. Surgery 2010;147:536-41. 11. Tsinberg M, Duh QY, Cisco RM, Gosnell JE, Scholten A, Clark OH, et al. Practice patterns and job satisfaction in fellowshiptrained endocrine surgeons. Surgery 2012;152:953-6. 12. Shin JJ, Milas M, Mitchell J, Berber E, Gutnick J, Siperstein A. The endocrine surgery job market: as survey of fellows,
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