Presidential Address: The Common Denominator and the Bottom Line I . \ a

Stanley J. Dudrick, MD

Presented at the American Society of Parenreral and Enteral h'utrition, Second Clinical Congress, Houston, Texas. February 4, 1978. Requests for reprinrsshould be addressed to Stanley J. Dudrick. MD. Chairman. Department of Surgery, University of Texas Health Science Center. Iloirston. Texas 77025.

THE JOURNAL OF PARENTERAL A N D ENTERAL NUTRITION

While contemplating the theme of this first formal Presidential Address to the membership of the American Society for Parenteral and Enteral Nutrition, countless thoughts emerged from my mind as I searched for an appropriate and relevant topic of potential interest to you. I was forced to ask myself the questions: Why was the American Society for Parenteral and Enteral Nutrition formed? What are its purposes for existence? Who are its members? What is it really all about? It occurred to me that in attempting to formulatereasonable answers to these queries, a suitable topic for discussion might become manifest. Obviously, each of us would have a series of responses to these four questions which would be uniquely personalized, and, to some extent, would elucidate and justify our own reasons for being here today. My personal understanding and beliefs are that this Society was formed by a very highly motivated, dedicated and talented nucleus of people who sincerely felt that there was no other group in existence which could, or would, cope effectively with the myriad problems associated with providing optimal or even adequate nutrition to all patients at all times under a wide variety of circumstances, either enterally and/ or parenterally. The basic purpose of the Society was to gathertogether a diverse group of people with a common interest in solving the problems for achieving the ultimate goal of optimal nutrition for all people at all times, and having an intense interest in, and earnest desire for, communication and interaction with each other. From this pinnacle of mutual education and intellectual stimulation, the hopes and expectations are that eventually, through a continuous and ambitious series of multifocal educational endeavors, we will not only exchange the latest scientific and clinical information and data, but we will share it with all of our other colleagues in the multiple disciplines of medicine and its allied professions. Indeed, an additional goal is to clarify and maximize the nutritional knowledge of all of our fellow men. The membership of the Society consists of physicians of all specialties, basic scientists, nutritionists, pharmacists, nurses, dietitians, technicians and allied medical professionals, together with industrial and other lay persons with common interests in the judicious applications of advances in the principles and practices of parenteral and enteral nutrition. Finally, I had to attempt to answer the last and most difficult question: What is the American Society for Parenteral and Enteral Nutrition really all about? Here, at last, I found the topic for my presentation today. The end result or bottom line of all of our individual and collective efforts, once again, is the provision of optimal nutrition to all people tinder all conditions at all times. This is such an obvious and idealistic basis for our 13

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existence that it does not really lend itself readily to further comment, elaboration, discussion or debate. We are unalterably dedicated to attaining that lofty goal. On the other hand, in my attempts to. derive and define the common denominator of the members of our Society, it occurred’to me that it was not mkrely an interest and talent in the nutritional arts and sciences, but basically, a genuine individual and collective humanism that has brought us together and binds us. Although optimal nutrition may be our bottom line, our common denominator is humanism. Webster’s simplest definition of humanism is “a mode or attitude of thought or action centering upon distinctively human interests or ideals.” What could be more humanistic than t o attempt t o guarantee the delivery of optimal nutrition to all people under all conditions at all times? You, my honorable colleagues and fellow members of the American Society for Parenteral a n d Enteral Nutrition, fundamentally, are humanists, and our common denominator is humanism. Moreover, it is your outstanding characteristic and your major motivating force. Throughout the centuries, humanism has been regarded variously as the attitude of mind which attaches primary importance to man and to his faculties, affairs, temporal aspirations and well-being. It has often been regarded as the attitude characteristic of the Renaissance in Western Europe. The Greek and Roman classical writers regularly distinguished the human or humane from the bestial on the one hand, and, o n the other hand, from the divine. In understanding and defining humanism, it is important t o differentiate it from human rights, which represent our fundamental freedoms without distinction as to race, sex, language or religion. In all probability, the definition, establishment, protection and preservation of human rights have been the subject of considerable thought, debate, controversy and other forms of intellectual expression ever since man apparently inherited the earth. Although the input into such idealistic endeavors has increased greatly both in quantity and variety throughout history, mankind is still far from unified in agreement about what even constitutes a human right. Evidence for this dilemma can be gleaned from virtually every form of communication today, especially since President Carter has chosen to make a worldwide political, and perhaps humanistic issue, of man’s rights. There has always been an active and keen interest among those who practice three of the most ancient professions-the ministry, the law and medicine-in defining and protecting the rights of the individual. Indeed, throughout the centuries of man’s existence, a seemingly generic concern for human values has punctuated his insatiable quest for good health. Although humanism has been defined or expressed variously as a 14

special regard for humanistic studies, a pervasive concern for human welfare or a philosophy that regards man as innately valuable, it has been and remains one of the primary elements of the healing arts. By whichever one or combination of these definitions, or perhaps even by .some newer and more unique construct, little doubt exists that there is a real and pressing need for re-examination of the role of humanism in the practice of medicine today.’ Ruminations of this nature are not unique and have been expressed more succinctly and with greater erudition by such men as Stewart Wolf who said: “It is not just a pious thought that medicine is more than a science, more than just an art or profession. As it has to do with the fulfillment of a man and his health, it is one of the humanities. Whether practiced in an ivory tower or at the crossroads, medicine must concern itself with human values.”* During his work in Africa, Albert Schweitzer coined an expressive phrase for humanism in medicine. He called it “reverence for life.” He implied reverence for the uniqueness of the patient as a whole, singular person in all of his mental, emotional and physical complexity. This does not imply, however, a subjugation or secondary role of the scientific aspects of our profession. On the contrary, today’s physicians, nurses, pharmacists, dietitians and other medical professionals must be educated in biosciences as never before, and must be equipped with a sound knowledge of the basic biologic laws underlying the properly functioning organism. Moreover, we somehow must maintain pace with, and selectively use, the growing store of scientific knowledge and technology which is forever putting new, sophisticated and more powerful diagnostic and therapeutic tools into our hands. But as we practice our profession, we must constantly remain alert to, and concerned with, the order, rationality and quality of the lives we are attempting to aid and pre~erve.~ In this country, perhaps the most illustrious and effective proponent of the humanist view during the past century was Sir William Osler. Osler was an unparalleled practicing physician, a premier teacher of clinical medicine was thorough preparation in the medical own lifetime. However, his magnificent achievements consistently were leavened in thought and action by a genuine humanism. Indeed, while Osler always emphasized that the ultimate basis for competence in medicine was through preparation in the medical sciences, he underscored the importance of the whole patient as the focus of all clinical activity. He often told his students, “Care more particularly for the individual patient than for the special features of the disease.” In another often quoted remark he said: “The practice of medicine is an art, not a science; an art in which your heart V O L U M E 2 I N U h l B E R 1 I 1978

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will be exercised equally with your head.”‘ Ideally, of course, medicine should be a bridge between those two great spheres of activity; humanism, which concerns itself with the inherent worth of the patient as an individual, and science, which brings technological knowledke to the service of that individual. It is incumbent upon ill ofus t o be both humanists and scientists simultaneously. There was a time in the not so distant past, when, by default, humanism constituted the major component of .the practice of medicine. Our limited scientific knowledge initially imposed upon us the handicap that wecould offer our patients empathy, concern and compassion for their well-being and little else, aside perhaps from a bit of blqodletting or purging or cupping now and then. Fortunately, achievements of modern science and technology have radically altered that dismal picture, but we are still not far removed from the jungle. Science has not brought us Utopia. In medicine, as in many other disciplines, there is a n increasing awareness that technology alone cannot provide all of the answers t o our problems. Ours is a science-dominated society, and yet, for all of the advances science has provided, man is seemingly no happier for them. Keen observers note that he remains lonely, alienated and somehow often afraid of what he has wrought. He senses the inherent danger of becoming the victim, rather than the manipulator, of his scientific toys. These concerns-fears, if you will-have led t o the development of outright antipathy between the sciences and the humanities as each claims t o offer the ultimate solutions t o our problems3 The well-known British philosopher-scientist, C.P. Snow, in his provocative lecture “The Two Cultures and the Scientific Revolution,” spoke eloquently of the situation, describing the sciences and the humanities as divided into two hostile camps, glaring at each other over an ever-widening gulf.’ Medicine illustrates such a gulf all too well. It is a discipline inherently dependent upon the cooperation and mutual understanding of the two cultures-the accomplishments of science give us the means to heal, but its essential raisoii detre is a humanistic one. Yet in medicine, as in so many other areas of our society, the two cultures are seemingly at loggerheads. Moreover, ’as science expands our knowledge and capabilities, it creates new problems whose solutions are not exclusively scientific. Achievements of the biomedical sciences have brought us face t o face with questions whose answers are as much in the realm of philosophy, ethics, morality and lifestyle as in the realm of science. Some of the most difficult issues confronting modern medicine, such as epidemic coronary artery disease, the congenitally defective newborn infant, iatrogenic diseases and disorders, and the treatment of the terminally ill fall into this TI{E JOURNAL OF PARENTERAL AND ENTERAL NUTRITION

category. The paradox is that while modern medicine has rectified the ancient imbalance which for so long heavily favored humanism, it has simultaneously created a situation in which the need for humanism is now more important than ever.3 These concerns have led to growing uneasiness at every level of our profession. Much of the ferment and turmoil in our hospitals, medical schools and universities, and the critical articles that appear more and more frequently in our professional journals and in the lay press are its most obvious manifestations. As one student of medicine put it:

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Are we physicians or organic mechanics? Are we technically proficient, but insensitive to human values? Have we lost sight of the ideal that the patient is more than acollection ofcells. organs and organ systems suscepiible to physical and biological 1aa.s; that he is a whole person with feelings and emotions, the product of a complex biological. emotional, social and cultural milieu. all of which affect his health and our diagnosis and treatment?

The practice of medicine requires knowledge and skill, frequently labeled as the science and art of medicine. Yet knowledge and skill are incomplete without the steadying infrastructure of humanistic values and objectives. The re-examination of these values in medicine and society will continue as long as physicians and other health professionals strive t o understand and renew their ideals3 It is not fashionable these days t o speak of bedside manner. The famous painting by Luke Fildes, showing the doctor in a vigil beside the bed of a sick little girl, is nowadays taken t o suggest the erstwhile impotence of medicine in the face of a serious infection. We seem t o have made a complete substitution of miracle drugs, therapies and technology for the personal influence of the physician and other health-related people. From the standpoint of the patient, it is a poor swap.6 A naturally humanitarian attitude and an interest in people have traditionally been considered important attributes of a good practitioner of the healing arts. They are no less important today. In fact, there is also a need for all of us t o have some knowledge of psychology and psychiatry, and a lively interest in what makes people behave as they do. One hundred years ago, a physician could d o a n effective j o b with less familiarity with behavioral sciences, but that was when hospital wards were filled with typhoid fever and puerperal sepsis. People were dying in large numbers from pneumonia and diphtheria. Today, birthratesarelower, peoplelivelonger, and in the wards of the hospital such diseases as hypertension, emphysema, peptic ulcer, diabetes mellitus, gastrointestinal tract malignancies and various inflammatory bowel disorders predominate-diseases, in the view of many, that reflect the wear and tear of living. Antibiotics and hygienic practices are diminishing the 15

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prevalence of infectious disease, and have altered the requirements for good health delivery, but they have not simplified our jobs. In the treatment of any disorder, the attitude and behavior of the practitioner will weigh heavily in the balance. A pill, potid0 o r even a surgical procedure administered with personal interest and enthusiasm and with the promise of hope has the greatest chance of success. Similarly, bedrest, nutrition and others of our therapeutic rituals owe a part of their success t o the quality of communication between the member of the health care team and the patient. In our therapeutic dialogue and interaction with the patient, there are several measures that may help bring the patient t o a more constructive and less costly adjustment t o his world. Above all, we should display a genuinely earnest and empathetic interest in the patient as a person. We must encourage him t o confide whatever doubts and conflicts he may care to discuss and t o listen attentively without implication of judgment or censure. The reassurance and emotional support for the patient which stem from our transmitted attitude of concern, interest and acceptance of the patient and his problems have been shown t o be among the most powerful therapeutic tools at our disposal. As a surgeon, I cannot resist mentioningan example of specific relevance and pertinence t o myself and my colleagues. Several years ago, it was shown that deprivation of body members or organs by surgery commonly resulted in serious psychological difficulties which often went unrecognized by most physicians and surgeons. The loss of a n organ as from amputations ofall sorts, plastic and reconstructive procedures, multiple o r extensive intestinal resections, and most important of all, abdominoperineal resection with colostomy, often impaired a patient’s self-esteem or his feelings of acceptability by family or friends. Many intelligent patients have such a poor knowledge of anatomy that they are likely t o conjure weird and fanciful impressions of the results of surgical operations. It has been shown that many of the problems of postoperative rehabilitation can be avoided by simply discussing with the patient, prior t o operation, the nature of the postoperative handicap and the possibilities for adjustment. If the patient is allowed t o develop a firm, sympathetic and trusting relationship with his surgeon, he can tolerate subtractive surgery better than he can if merely given explanations. When the surgeon is “too busy” t o allow a suitable relationship t o develop with his patient, neither he nor the patient can expect t o realize maximum potential for recovery and rehabilitation.6 A human being’s ability t o tolerate tragedy and disaster can be enhanced tremendously by the presence of a strong, understanding and empathetic person. Part of our 16

j o b is to share the burden. There is no place in modern medicine for the attitude of hurried austerity which was so popular among surgeons, physicians and other members of the health care teams of a generation ago. At the time, while making great strides in assuaging or preventing -misery and pain, they inadvertently were generating other miseries and pains often less bearable and longer lasting. There is always a feeling of urgency “to d o something,” and frequently this inward urge is strongly reinforced by demands of the patient’s family. The one important thing to d o is t o see the patient frequently, to provide him often with the reassuring presence of doctors, nurses and other members of the staff. It-is also important t o speak frequently with the family, if only t o tell them that there is no change, and t o be available t o answer their anxious questions. The key t o equanimity of the patient who is in jeopardy, and of his family, is the early establishment of a n interested therapeutic relationship, giving the patient the assurance that every member of the health care team is doing his utmost and will support the patient and his family t o the last.6 Why have I spent so much time discussing the essentiality of humanism in the practice of medicine? Among the many reasons, these stand out in my mind: 1. While students usually enter our universities and professional schools with humanistic concern and a deep social consciousness, our medically oriented institutions of higher learning seldom make a conscious effort to nurture, examine and reinforce these values. During their long years of training, students tend t o lose some of the idealism and social commitment which contributed initially t o their choice of a medical career. They often become disillusioned and cynical through the years of struggle as their feelings of caring and compassion are gradually but steadily extinguished. 2. New technologies and treatments in medicine seem inevitably to give rise t o a new group of ethical and social dilemmas. Students must be given the necessary training t o cope with these dilemmas in their full complexity and t o understand the threat t o human values that is implicit in the technology of medicine. Their responses will relate to human values that touch on the nature, dignity and the future of mankind. Thus, the explosive power of new knowledge and techniques forces constant alterations of professional practice and re-examination of many traditional values in the care of patients. 3. The art of medicine must be kept in proper balance with the science of medicine. In other words, the human relationship must be maintained. Involved in the treatment of the patient is the human element in the physician himself, that is, the physician’s use of the self as an instrument of healing. The physician is more than a technician or a mechanic-he is a healer. If students fail t o VOLUhlE 2 / NUhlBER I / 1978

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comprehend and embrace this dimension in the practice of medicine, they will become little more than civil servants in the expanding bureaucracy of medical practice. ’With just a cautious look over your,shoulders, will see the various vested interest grodps of the federal governmeni looming increasingly Aoser and larger in their mutual obsession with capturing and controlling your profession. One currently existing blatant example of how our basic human rights and those of our patients have already been compromised by big government is manifest by the constraints imposed upon the Food and Drug Administration, who, sanctioned by law, are answerable only for untoward complications of foods and drugs which are available for public consumpt h . On the other hand, they legally are not answerable, liable or held responsible for their actions in withholding effective forms of therapy, which action may result passively, though legally, in the loss of life. We have obviously gone too far in our attempts to protect and defend ourselves and our patients by legislative fiat and not far enough in propagating humanistic values in our medical colleagues, our legislative representatives and indeed, in all of our fellow men. We are desperately in need of revision of our federal bureaucratic system and require enactment of new, rational and pertinent legislation if we are ever to achieve our bottom line. Otherwise, many or most of us may not live long enough to see our patients reap the therapeutic benefits of knowledge and technology which we already possess and are continuing to acquire at a geometric rate. 4. Because medicine’s history shapes the profession and gives it its character, our relationships with our patients are tempered by the history of the profession. A study of medicine’s past, therefore, can enrich our understanding of the privileged relationships we enjoy with our patients. Moreover, ’without an informed understanding of medical history, our ability to provide the best of medical care to our patients is diminished.’ Indeed, an enormous amount of valuable time, energy and resources are lost annually as a result of so-called research which has not only been carried out in the past, but often in a more scientific and meaningful manner. I strongly believe that students and trainees in all aspects of the medical profession be encouraged to learn more of medical history during their formal education and training rather than later in their careers at their leisure, as is more often the case. 5. As a physician-scientist, I have become increasingly concerned with the attitudes toward, and the understanding of, clinical research. The federal government and its myriad agencies, various “do-gooder” lay organizations, the clergy, the legal profession, and yes, countless numbers of our own profession, in their zeal t o “protect” THE JOURNAL OF PARENTERAL AND ENTERAL NUTRITION

the patient from attempts to help him recover from desperate straits, have actually denied the patient his optimal rights for survival with minimal morbidity by the restrictions they have increasingly imposed upon clinical research and the application of the fruits of such endeavors inahurnan beings. Although I a m well aware and understand the basic underlying philosophy of, and the indication for, the institution and enforcement of policies and procedures regulating human experimentation, I also recognize that such laws, while designed fundamentally to protect the many, in fact often sacrifice the welfare of a great many for the protection of a few. Instead of establishing committees for the protection of human subjects, we should establish committees t o insure the welfare of human subjects. I regard with disdain and disappointment the perceived necessity of many of our fellow men for a formal body “to protect” human beings from physicians and other members of the health care team. However well intentioned was the genesis of this concept, it has served t o cause dedicated and competent physicians, clinical investigators and others to act timidly and defensively when they should be acting boldly and innovatively to alleviate or obviate the ravages of disease in their patients. Moreover, it has cast a stigma in the eyes of many upon the highly motivated, idealistic physicianinvestigator who endeavors t o offer his patients the newest, albeit incompletely proven, methods of therapy in a desperate attempt t o help them. Bear in mind that the Miranda decision, which was conceived and designed to protect the constitutional human rights of all individuals, but primarily those of the innocent, has in reality essentially backfired. It has become one of the greatest impediments to just law enforcement and the most welcomed benefactor of the repeated and hardened criminal elements in our society. It is only a matter of time until it will be reversed or repealed, or surely crime will become a sanctioned way of life. It is a cogent example of a well-intentioned idea gone berserk. O n the other hand, I am well aware of, and admit to the fact that without such a law a few innocent people will be treated unjustly. However, to use a n analogous example: just because an aircraft might someday crash into a schoolhouse with the loss of many lives, it is not rational to outlaw air travel or collective education. Our world is full of similar examples in which one’s very existence is associated with a finite, seemingly irreducible number of injustices if organized society is to continue to exist. The price of progress must be paid if progress is to continue. It almost need not be expressed, that any new form of therapy should be tested thoroughly and completely to the satisfaction of several investigators in the laboratory, both in vifroand in vivo, with appropriate animal models in a reasonably comparable fashion whenever possible before being employed 17

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in man. However, it must also be clearly recognized and understood that t o establish true relevance of research data in man, man must eventually be the experimental subject. A man is not a test tube,, a rat, a dog or even a chimpanzee-and indeed, reaction$,observed in man may be quite different from, or even opposite to, those obtained with any laboratory model. Moreover, there are many disorders deserving study, perhaps demanding study, for which there are no known or likely reasonable experimental models. For example, how does one study agents for the relief of angina ultimately except in man; how can one study the etiology, pathophysiology and therapy of granulomatous enteritis or ulcerative colitis except in man, when no other animal appears to be afflicted by these disorders; or, how can one design safe and effective techniques for stereotactic surgery of the human brain unless rational experiments are actually carried out to map the areas of the brain in human beings? It is obvious that sooner or later one must “bite the bullet.” In reading the most widely quoted reference on subject matter of this nature, I find in the Bible that God commands us in Deuteronomy, Chapter 30, Verse 19: “I have set before you life and death, the blessing and the curse. Therefore, choose life, that you may live again.” Of what relevance is this? If a patient is suffering from a potentially fatal disorder, what should be done for him if all conventional forms of therapy have been exhausted ineffectively? The Talmud instructs us most emphatically that one must never put his life in jeopardy. It tells us: “One does not walk next t o a shaky wall; it might fall o n his head-might kill him. One does not walk under a rickety ladder, it might fall on him and hurt him. One does not walk in a ruined building because it might fall down o n him, may shorten his life, may endanger his existence.” Sepher Ha-Chasidim, more than 800 years ago, instructed with this allegory: A man is deathly ill and he is expected to die at any moment. His physician cautioned all not to move him because he might then die even earlier than expected. But what if the house in which the patient is lying catches on fire? Even though the doctor originally said that the patient is not to be moved because his life might thereby be shortened, should not the man be m’oved from the burning house?

Therein lies the common clinical dilemma. If the patient is moved, an earlier death can be anticipated. On the other hand, if he is not moved, he will surely die from asphyxiation or burns. Therefore, we must take a chance-that’s the key phrase-we must take a chance. Even though there is an obvious risk in moving the patient, he will surely die if he is not moved. But, by taking him out of the house, we might actually extend his life. Regarding walking next to shaky walls, under rickety 18

ladders and in ruined buildings (or even going out late at night these days in high-crime areas), one should not d o these things because no good is likely to come of them. However, in regard t o the sick man in the flaming housetrue, it is dangerous t o move him, but something good* that’s another key phrase-something good may resulthe may live longer. This justifies the action taken according to Judeo-Christian law. When we have attempted to cure or relieve one of our patients of an affliction, disease or indeed, malnutrition, by every form of established and proven therapy known to us and to our colleagues, it is my sincere belief that the patient at that point has the right, yes, the human right, to be made aware of the fact that he might possibly benefit from a new, experimental, and even unproven form of therapy if he and/or his family is agreeable t o its use in him. I am infinitely more concerned about our daily denial of this right t o our seriously or critically ill patients than I a m of the superficial concern of the many wellintentioned “do-gooders” who seem to derive enjoyment and satisfaction from spending most of their time trying to regulate the activities of productive people rather than being productive themselves. I a m a strict advocate of, and adherent to, the philosophy of President Theodore Roosevelt, who said: 11 is not the critic who counts; not the man who points out how the strong man stumbled or how the doer of good deeds could have done them better. The credit belongs to the man who is actually in the arena; whose face is marred with dust and sweat and blood; who knows the great enthusiasm, the great devotions and spends himself in a worthy cause. Who in the end knows at best the triumphor highachievement,andattheworst, if hefails, at least fails while daring greatly so that his place shall never be with those cold and timid souls who know neither victory nor defeat.

It is with this background and philosophy in mind that the members of our Department of Surgery at The University of Texas Medical School at Houston have been privileged to garner the experimental and clinical results with which many of you are familiar in our persistent unwillingness to accept the “obviously inevitable.” Our departmental accomplishments and those of all of us in ASPEN are clear manifestations of the basic tenet that nutritional therapy should begin at the simplest effective levels and progress gradually to the more complex, as necessary, until all known forms of conventional treatment have been used rationally to their utmost effectiveness. The average or ordinary practitioner. has fulfilled all of his responsibilities when he stops there. However, it is not he whom we emulate and, in our quest to be extraordinarily good and humanistic practitioners, we feel strongly that it is not only our wish, but our responsibility to take the measures above and beyond the existing standards in order not to deprive the VOLUhlE 2 I NUhlBER I 1 1978

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patient of his right to maximum benefits of the skills and technology of modern medicine. Until such time that optimal digestion, absorption and assimilation can be maintained via the alimentary tracts of all patients at all times, a comprehensive knotvledge of parenteral nutrition- will be an essential to61 in the armamentarium of the most enlightened and successful physicians and other members of the health care team. Just as the master practitioners of the past, and even present, had to gain expertise in anatomy, pathology, physiology and pharmacology, physicians, surgeons and other health care professionals of the present and the future must be proficient in their knowledge of biochemistry. From a practical point of view, parenteral nu>ition represents the very basis of clinical biochemistry in that this feeding method may be the only means by which the substrates which fuel and support all cellular processes may be provided to the organism. In this regard, the concepts of many who practice medicine today must be updated or changed considerably. However, this is not without precedent. Only a few decades ago, the term “shock” meant to most people that a patient was anxious and apprehensive, lying prostrate, feeling cool and clammy, appearing pale and perspiring. Others described “shock” as a state in which the systolic blood pressure was below 90 mm Hg, and the patient had a pulse rate above 120 beats per minute, a faint, thready pulse and a rapid, shallow respiratory rate. However, these descriptive terms did not define shock, and we all know now that what shock really means is that perfusion of the body’s tissues is sufficiently impaired to interfere significantly with the exchange of oxygen, carbon dioxide and other substrates and metabolites at the capillarycellular membrane. Future generations will undoubtedly alter this definition further. In an analogous fashion, our concepts about nutrition must change. Food is the nutrient material which is ingested. Diet is that food and drink which is regularly consumed or provided. However, nutrition is the sum of the processes by which an organism assimilates and utilizes food substances. Thus, nutrition really occurs at the cellular level, where all of the biochemical reactions essential to life and its functions, take place. Whatever‘is ingested into the alimentary tract by mouth or by various tube feedings has no chance of participating as substrate within the body cell mass until it has been modified considerably by the organs of the digestive system, Nutrition is basically the provision of biochemical substrates in the quantities and ratios which are required for’normal intracellular functions. In this regard, what is given as nutriment parenterally must be in a form which is suitable, and preferably optimal, for immediate use in the metabolic pathways of the body. Moreover, due conTHE JOURNAL OF PARENTERAL A N D ENTERAL NUTRITION



sideration must be given t o the changes in the requirements for nutrient substrates which occur during the various pathophysiologic conditions and disorders that we are called upon to treat. Ever since the discovery of the circulation, we have been increasingly able to provide nutrition by parenteral means to patients requiring this mode of therapy. In fact, at this point it is possible t o provide a truly complete diet by vein. However, as sophisticated as our current parenteral nutritional regimens may appear to be, they represent only one small step toward our ultimate goal of complete knowledge of the metabolic cellular derangements induced by all forms of pathology, and our ability to prevent or treat them specifically and effectively via total or adjunctive parenteral means. In the beginning, the impetus for the development of parenteral therapy was, and continues t o be in some quarters, an attempt merely to provide the water, electrolytes and the minimal calories essential t o support life. As knowledge and experience accrued in this vital area, attempts were made to maintain homeostasis in all aspects of cellular nutrition, that is, for water, electrolytes, amino acids, carbohydrates, fats, vitamins and trace elements. Soon it became apparent that no single -parentera1 regimen could be ideal for all patients with a wide variety of pathological processes, nor for all age groups, nor for the same patient during all aspects of a particular disorder. This has led to tailoring specific parenteral nutrient regimens t o the patient and/or to his pathophysiologic process. Thus, we now have at our disposal a wide variety of maintenance and therapeutic formulas for pediatric and adult patients, and for the adjunctive treatment of patients in renal or hepatic failure. Moreover, considerable efforts are underway and must continue in order to understand and define the specific nutrient requirements which accompany the various forms of cancer, major trauma, extensive full-thickness burns, sepsis, immunologically related diseases, genetically mediated metabolic disorders and even atherosclerotic cardiovascular and peripheral vascular disease. Although our current special substrate mixtures are crude at best, they represent a giant step in the right direction, and are the harbingers of the future of specifically formulated parenteral nutritional therapy. As the relevance of adequate parenteral nutritional support in the management of critically ill patients has become obvious, thoughtful members of the health care team have recognized the logical extension of these effective practices and principles to the less seriously ill patient. Therefore, a whole host of parenteral nutrition regimens have been designed and infused by various routes and techniques either to improve standard salt and carbohydrate peripheral therapy or to serve as a more 19

PRESIDEKTIAL A D D R E S S

sensible adjunct t o other forms ofnutrient therapy. It is of great interest and satisfaction t o me t o note the progress being made in this important area. As has been the case with most advances in medicine,., there have been differences initially in the degree of success obtained with widespread application of new techniques. But, as additional knowledge and experience have been gained, improved results have generally followed. Conscientious attention t o established principles of total parenteral nutrition is essential if the ever-present threats of thrombotic, septic, mechanical and metabolic complications are t o be minimized or controlled. Considerable experience has been gained by many interested groups throughout the world in the clinical investigation and the practical application of total parenteral nutrition, and I a m delighted and honored t o see so many of the world’s experts in this area in this room today. Moreover, it has been gratifying t o witness the extent t o which these clinical developments have stimulated the related basic and laboratory research so essential t o our continued advancement in this field. I a m equally pleased t o see how many of our basic science colleagues have come to our aid in this regard. Finally, I would like to share with you some of my thoughts about, and expectations for, the American Society of Parenteral and Enteral Nutrition. First of all, I a m looking forward t o the day when we are accepted as legitimate and equal members ofthe nutrition team by the various other national and international nutritionoriented organizations. The time has arrived when those of us interested in parenteral nutrition, specialized forms of enteral nutrition and the nutritional care of the critically ill hospitalized patient are not segregated as some form of rump group within or astride our more senior and prestigious societies or, even worse, ignored completely by them. We are, and effectively have been, legitimate members of the nutrition team despite the fact that the majority of us have not earned the commonly recognized and accepted nutrition credentials. We have “earned our spurs” the hard way, however, because we have been faced with having to provide adequate nutrition t o the most severely malnourished and most critically ill patients in our population. Moreover, we have accomplished a great deal in the process by demonstrating beyond a shadow of doubt the true relevance of optimal nutrition clinically. This has done more t o stimulate interest in nutrition among our students and trainees, and indeed, our clinical colleagues, than virtually all other past efforts combined. Perhaps total parenteral nutrition and specialized enteral nutrition is n o more important than efforts being made throughout the world in nutritional epidemiology, idiosyncratic dietary studies and the many other nutri-

tional aspects of public health and community medicine, but they certainly are not less important. By marshaling together our talents and resources, achievement of the bottom line of all nutritionists may eventually be a reality. Another important hallmark for us to achieve is t o nGmber among our membership at least one representative from every hospital and health care facility in America. As ambitious an undertaking as this may now seem, it certainlylies within the realm ofpossibility within the next year or two. Third, we should act individually and collectively t o insist that all hospitals must- have a competent working nutrition committee as a prerequisite for accreditation. A fourth goal is t o achieve the scientific support of our membership for the Journal of Parenteral and Enteral Nutrition. It is our official organ of communication and our window t o the world. Only when we have sufficient pride in our Society and our Journal to submit our best work for publication therein will we have satisfied our obligations of membership in ASPEN. We will bejudged by many by what is contained within the covers of JPEN. Therefore, I urge your utmost cooperation in providing the Editorial Board with sufficient first-class material t o fill the Journal. The quality and quantity of the material presented at this Second Clinical Congress is evidence that we can accomplish this goal with ease. Fifth, I hope that ASPEN will soon emerge as a formidable voice for the consumers of the specialized services our membership provides. In this regard, we must work toward having our governing bodies pass new or amended legislation which is rational and updated t o our progress in nutrition. Many of the rules and regulations which govern the Food and Drug Administration are inadequate or sufficiently antiquated that they are not applicable realistically. The guidelines for efficacy of nutrient substrates must be liberalized t o the point that biochemical data are as acceptable as so-called clinical data. Minor changes in formulation of parenteral and specialized enteral diets must be possible, when indicated, by sound experimental data without declaring the modified formulation a new drug or food. We cannot afford to waste our time, talent and other resources o n foolish and pedestrian activities in response t o unreasonable rules and regulations of this kind. For patients who must endure prolonged hospitalizations, multiple operations, massive bowel resections and other major insults, we must press for some form of catastrophic health care legislation to support these unfortunate people, or they are doomed t o death and their families t o ruin. Although the federal government is very wary of another chronic home dialysis type program, they can no longer evade their responsibility to provide some form of relief to patients who must accept VOLUhlE 2 I NUklBER 1 / 1978

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supplemental or total parenteral nutrition as an inevitable means of support for the rest oftheir lives. Medicare and Medicaid policies must also be altered and liberalized in order to include payments for the heroic types of nutrition we must proyide to patients in ordef,to insure their survival or, at the very least, to reduce’their morbidity. Other third-party health insurance providers should then be required to follow suit. The membership of ASPEN can be a great stimulus and resource to groups of consumers who might want to express theirwill and exert their influence in this vital area. Finally, the common denominator and bottom line belong to the world. Only through the exchange of ideas and data with all peoples can we in ASPEN achieve our bottom line. Our common denominator is an international one in reality, and I would encourage every member of ASPEN to participate directly or indirectly in the International Society for Parenteral Nutrition as a means of furthering all of our goals with the greatest effectiveness and dispatch. The “breaking of bread” together, literally a n d symbolically, is one of the most important interactions we have with our fellow men everywhere. I would like to close my remarks today with these thoughts. There is no pathologic process which can be expected to respond more favorably to therapeutic endeavors when the patient is in a state of malnutrition than when he is well nourished. Therefore, it is not merely advisable, but absolutely essential that all members ofthe health care team, regardless of their specialty or area of expertise, have a practical working knowledge of the identification and effective management of nutritional and metabolic problems in their patients. This is

especially important in seriously ill individuals in whom the provision of adequate parenteral nutrition may be critical to minimizing morbidity and maximizing survival and quality of life. It has been a virtually indefinable experience for me t o have witnessed the growth, development and progress of total parenteral nutrition and specialized enteralnutrition during the past ten years. The joy and satisfaction I personally have experienced in witnessing this phenomenon is indescribable. The pride I have felt and enjoyed during the past year as a result of having been chosen by you as the first president of the American Society for Parenteral and Enteral Nutrition has been enormous. I sincerely appreciate the help and cooperation you all have given me; I am grateful for your professional and scientific comradkry and personal friendship; and I am deeply honored for the opportunity to haveserved as your president.

REFERENCES 1. hlcGovern PH, Burns CR: Humanism in Medicine. Charles C Thomas Co, Springfield, Illinois, 1973. 2. Wolf S, Goodell H: Behavioral Science in Clinical Medicine. Charles C Thomas Co, Springfield, Illinois, 1976. 3. McGovern JP: Humanism in medicine. Harris County Physician, Houston, Dec 1976. 4. Bean WB: Sir William Osler Aphorisms From His Bedside Teachings and Writings. Charles C Thomas Co, Springfield, Illinois, 1968. 5. Snow CP: The Two Cultures and the Scientific Revolution. The Rider Lecture, Cambridge University Press, New York, 1959. 6. Wolf S: The doctor as a therapeutic agent. Harris County Physician, Houston, Dec 1976. 7. Knight JA: Medical education’s goal: The humanistic physician. Harris County Physician, Houston, Dec 1976.

The Provision of Optimal Nutrition to all People Under all Conditions at all Times

THE JOURNAL OF PARENTERAL A N D ENTERAL NUTRITION

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Presidential address: the common denominator and the bottom line.

Presidential Address: The Common Denominator and the Bottom Line I . \ a Stanley J. Dudrick, MD Presented at the American Society of Parenreral and...
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