ANNALS OF SURGERY September 1979

Vol. 190

No. 3

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Presidential Address: The Unfinished Painting OLIVER H. BEAHRS, M.D.

DR. MuRRAY, members of the American Surgical Association and guests, to be elected President of the American Surgical Association is the greatest honor that could come to an American surgeon. I am very humble in recognition of this, for there are many of you, members of this great and distinguished Association, who deserve this recognition more than I. In accepting the presidency this year, I do it not only with humility and in great appreciation of the honor you have bestowed upon me, but also in recognition of the great medical institution with which I have been associated for almost 40 years-founded by two brothers, one President of the Association in 1913 and the other President in 1931 -and in recognition of the meaning of the clinical practice of surgery. The last is what our profession is all about: educating ourselves and those about us to a high level of knowledge, evaluating the old and seeking out the new so that we can provide the best of our capability to our fellow man- the patient. Somewhere I have read that if you really want to make a good speech you should say, "to be seen, you must stand up. To be heard, you must speak out. To be appreciated, you must sit down." Possibly I should consider this advice, but I will take the risk and speak for a short while. During the past year, I have read the correspondence of Dr. William J. Mayo while he was President of the Presented at the Annual Meeting of the American Surgical

Association, Hot Springs, Virginia, April 26-28, 1979.

From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota

American Surgical Association. I would like to take note of several items. A letter to him from another member of the Association stated, "I guess we should not lug the women along but leave them in Chicago." A happy change has occurred over the years-our ladies are with us now and rightly so, since they contribute so much to us as surgeons and remain tolerant and interested in our "shop talk" during social affairs, meetings and at home, although they might be more interested in other subjects or activities. Their support makes it possible in many respects for members of the Association to hold the positions and the respect within the profession that they do. Our thanks to them. In another letter by Dr. Will to the President of the American Surgical Association in 1921, he expressed, among others, the thoughts that the American Surgical Association should not be looked upon as a private club. It seems to me that the Fellows of each generation are merely trustees, and that any American, without regard to race, creed, or color, who accomplishes the work that entitles him to membership is eligible, and that objections to him on personal grounds should not be tolerated.12 He later also stated that he thought it would be wise for the Association to choose for its Fellows more persons in their 30s to stimulate them to do their best.

0003-4932/79/0900/0265 $00.95 C) Copyright 1979 Mayo Foundation

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Ann. Surg. * September 1979 BEAHRS 266 Certainly this philosophy should continue to hold government has met with uniform failure in many, if not true today. Membership should be in recognition of most, of the programs it has undertaken, by interfering past and current achievements and future promise in with the marketplace. the fields of patient care, education, research and I recall seeing a quotation that has stayed with me medical socioeconomics. Our present and recent new because of, I think you will agree, its remarkable relemember classes reflect this attitude, and we look to vance to our times. It was from a speech delivered by a these new members for leadership in the field of American statesman to the governing body of his own time and Surgery now and in the future in our changing medical place. He declared that the budget should be balanced, and societal environment. the treasury should be filled, public debt should be Presidential addresses presented before the Associa- reduced, the arrogance of officials should be tempered tion over the years have included topics of scientific and assistance to foreign lands should be curtailed lest interest, medical education, research, review of the the state become bankrupt. And he advised that people history of the American Surgical Association (founded should be forced to work and not depend on governin 1880) and descriptions of the great men of surgery ment support. The statesman was Cicero, and he was and their contributions. All are subjects of interest and addressing the Roman senate some 2000 years ago. It of value, especially the last, because for us today, as is interesting that history does not change, and we do has been so well said before, we see as far as we do not always learn from the past. because we stand on the shoulders of giants. The William Simon, in his book, A Time for Truth, has groundwork and foundations have been laid for us by pointed out what government today has forgotten: our predecessors, and it is our obligation and In sum, individual liberty includes the individual's responsibility to maintain the excellence in our economic freedom, and the Founding Fathers knew profession for those who follow. Today, rather than it. had They good reason to leave the productive accover only a single aspect of what concerns the surgical tivities of men as free as possible. Their calculations, community today, my remarks will relate to what I like those of Adam Smith, were correct. When men regard as an important group of problems-education are left free the state to engage in productive action, by as it affects patient care, the patient-doctor relationself-interest above all, they do create the guided by ship, residency training, government relations and cost most efficient and powerful production system that containment and other socioeconomic issues. is to their possible society.17 In the past, our primary interests have revolved around the art and science of medicine. The socioeconomic It is our responsibility to develop further an efficient issues affecting medicine and health care were only and powerful production system-a system of health secondarily of interest. Today we are embroiled in care delivery that will offer people in our society quality controversy regarding the administrative structure of care and good health. Government is already in the act, providing health care, cost containment, quality as- so we must work with it to create the best system of surance of medical service, liability for unfavorable medical service, protecting, above all else, the patient's results, malpractice, recertification, relicensing, medical welfare. manpower and its distribution, second opinions and Rather than dwell on these issues without direction, I unnecessary surgery. would like to center my further comments on an Eiseman7 has stated in an editorial, Surgery's Great- unfinished painting by Brynjalf Stranderes (Fig. 1). est Challenge, "A horde of aggressive social planners Before it could be finished, the artist became ill from a and economists are rushing to solve our problem for vascular accident and never painted again. In his us. Like self-confident politicians dealing with warfare, frustration, he had slashed the picture. For many they consider the problem to be too serious to be left it was lost; eventually discovered, it was restoredyears and to the generals." framed in its unfinished state. It now hangs in the Mayo Unfortunately, the profession has not taken a leader- Foundation House, the former home of Dr. William J. ship role in these areas, and as a result, government, Mayo. A painting of medicine and surgery can never be industry, labor and the public have forced us into a finished. The future and the art and science of compromising position on many of these issues. We and surgery will always be changing, so that medicine the final have more often reacted rather than led. We must dream touches can never be applied. ofthe future and take the initiative. Government, because So much can be read into this painting-our heritage of its power and control of funds and with the encourage- represented by Dr. William Worrall Mayo and his ment of individuals or parties with evangelistic fever, the present by Drs. Will and Charlie, the future by wife, is playing a dominant role in shaping the future. Yet Joe and Chuck, teamwork as illustrated by the Drs. two

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FIG. 1. An unfinished painting of the Mayo Brothers by a well-known Norwegian painter, Brynjulf Stranderes, left incomplete when the painter suffered a cerebrovascular accident. The painting, nevertheless, depicts the field of surgery-heritage, teamwork and the art and the science.

brothers who worked as one along with their associates, surgical nurses and assistants, education by the observers in the gallery and science by the anesthesia equipment in the foreground; and the hand is outstretched to the unseen and never to be forgotten one, the patient. The painting is that ofthe world of surgery as it should be. If all of our concerns and questions regarding health matters were always made on the basis of what is best for the patient, the decisions would almost always be right. Unfortunately, as Schlicke16 has pointed out, ". . . that suffering human being, the patient, has become the 'consumer,' the dedicated physician who ministers to his ailments the 'provider,' and a respected profession and its allies are referred to as the 'health care industry.' " As physicians, we must be positive in attempting to

maintain a more personal relationship and not let a sense of coldness come between doctor and patient, as is implied by these terms. A further drift in that direction will lead to greater breakdowns in the best environment in which to provide health care to the patient, namely, one of mutual respect between the patient and doctor, society and profession. Compromises of ethics or principle should not be accepted if they interfere with what is considered best for the patient. Throughout the years, Dr. Donald C. Balfour, as surgeon-teacher and as Director of Mayo Graduate School, kept before the minds of the younger physicians at Mayo the principle that preservation of the physicianpatient relationship was the highest attainment to which a physician could aspire, and maintaining this would

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continue to constitute a real contribution to medicine regardless of the form medical practice might take. We should remember this and accept alteration in the form of medical practice only if this principle is maintained. Considering the patient an inanimate object, a consumer or a financial resource detracts from the relationship and hardly fulfills the requirement of the principle of Fellowship of the American College of Surgeons, which is stated as follows: "Each Fellow must demonstrate professional, moral, and ethical fitness. Surgery is to be practiced with scientific honesty, placing the welfare of patients above all else."2 The patient must remain a human being to the surgeon, whose primary concern should be to provide the best of medical care to him. Clinical practice, in addition to providing care, involves education of the patient, one's associates and the public. As Victor Johnson stated, The desire, the need to teach, is as old as the profession of medicine. The Hippocratic oath of antiquity admonishes the physician not only to care well for his patients, but to teach the art and practice of medicine to young aspiring also to become physicians. In no other profession is the urge to teach more compelling than in medicine. In truth, the very word "doctor" means "teacher."

Ann. Surg. * September 1979

care

of the patient and at some point in his training

finally participating? Unfortunately, if an educational program does not provide close and careful supervision of the student during his training period by an experienced surgeon, not just the resident a year ahead of him, our obligation to the patient, to all patients, is not being fulfilled. Loyal Davis, in an editorial, stated, Patients have always trusted a person, not a hospital. In spite of society's opulence in this day and age, this fact still remains true. They wish to choose their doctor and have his experience and interest in them as persons and also direct the entire plan of helping them get well. They also wish him to direct investigative studies and the order in which they will be done; choose consultants; and supervise writing orders for their medications. They cannot approve putting the reins of their care in the hands of the house staff. When they learn that interns and residents write orders, plan studies which experience would deem unnecessary, call consultants, and order their discharge from the hospital, they lose confidence and seek medical help elsewhere. The patient is and should be of primary concern to the physician and surgeon. He is not the jurisdictional right of members of the house staff.

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This is well illustrated in our unfinished painting. Medical education has undergone changes over the years. At first, it was strictly a preceptorship and frequently a proprietary arrangement between teacher and student. With the Flexner report,9 medical education changed and has gradually drifted to a program of graded responsibility and learning as the resident years pass, at times at the expense of the patient. The certifying boards, not always placing the patient first in consideration, too often look at the details of a program-the mechanisms, the administration, the right to anatomic territory or systems, a fixed pattern of training-and not at the end result, that is, at the evaluation of a welltrained surgeon, learned not only in the science of surgery but also in its art on the basis of having seen it applied by the experienced surgeon. It should be recognized that the resident can reach the end point in his training by varied routes and elastic programs. The Flexner report did not rule out preceptorship, but unfortunately many programs have drifted far from it. A residency is an educational program, and how can the student learn better than by close association with an established surgeon-observing his management of surgical problems and participating with him in the surgical procedure, watching mature surgical judgment being used in the

The patient has the right to choose a physician and to expect the best of him, irrespective of that patient's social or economic status. Socialized medicine would take away this right. With government and other third parties playing such an important role in financing medical care, members of our enlightened society expect to select their physicians and surgeons and to participate in decision-making or at least in selecting an alternative in management. Surgical training environments must accept this change and alter their educational programs accordingly. And this is not all bad, because the patient must come first-he or she deserves an environment, a decision and an action mechanism that offer the best of mature medical and surgical judgments, leading to the best of care. Although some educators might contest this, educational programs would be enhanced by this change. In a recent visit to a country where private medicine is illegal and an impersonal system is available to all, I found that an estimated 80% of the population seek private care so that they can select their own physicians and the medical service they desire. Even though this is illegal, the law is not enforced, because it is recognized that the population wants more than can be offered by a socialistic system. Although health care is considered by some to be a right, it is and should be a patient's

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FIG. 2. The painting "The Doctor" by Sir Samuel Luke Fildes. This illustrates so well the art of medicine and surgery-looking at the patient, touching him, contemplating the various factors to be considered in reaching a judgment regarding the management of the clinical problem.

responsibility-the right should be for the patient to expect quality care and to select the environment and physician to provide it. This does not imply that the resident or student does not participate in the care of the patient, but he or she should do so under the eye of the teacher during the whole of the training program. In this respect, I too would like to cite Henry Brooks Adams, as a predecessor of mine did: "A teacher affects eternity, he can never tell where his influence stops.'') The art of medicine is learned by observation -seeing it practiced. It cannot be learned from a textbook or by trial and error in the care of patients. To look at the patient, study his expression, feel his skin and pulseto touch- will often provide a better evaluation of the patient' s condition than will a study ofthe chart (Fig. 2). The best of patient care, however, is the melding of the art and science of medicine, and through this process proper judgement can be reached. As Dunphy has said, Remember that in surgery, because of the complexities of human biology, decisions must often be made on the basis of probabilities, not certainties, and a life may hang in the balance. Making the correct decision is what is called "judgment" -an amalgam of intelligence, knowledge, experience, and continuous

critical analysis of results. Like war it is hard. But it is better than war; it saves lives and binds men and women of good will together in deepest friendship.5 As Hall has pointed out in an editorial entitled The Surgery ofHesitation, "A surgeon may be endowed with superb qualifications but not be capable of carrying into action many simple operations because of a predisposition to vacillate." 10 The operating room is where the students need to see judgment exercised. The mature surgeon knows, or should know, surgical embryology, anatomy, gross pathology and the biologic behavior of disease. Evaluating the historical, physical and laboratory facts and the findings at the operating table, he should quickly come to a surgical judgment. Sophisticated and costly tests are not always needed. Once a decision has been made and the correct procedure has been decided upon, the surgeon should be so organized that the operation can be carried out in a stepwise manner with facility and in the shortest period of time consistent with safety. Generally speaking, when this is true, the patient benefits, and this is what surgery is all about. A surgeon might perform a procedure in an hour, and a resident under the preceptorship of a surgeon might do it in two hours, and this is acceptable; but when the same procedure takes four to six hours and without proper supervision, something is obviously

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wrong. Erlik has called this the "surgical disease."8 It is morally wrong to expose any patient to preventable risks of morbidity and mortality as a result of hesitancy in making judgments or of being unorganized in carrying out a surgical procedure. Owen Wangensteen has recently proposed a "Teacher's Oath." He noted, In recent years complaints from medical students that they rarely see their senior clinical teachers are reechoed frequently in the halls of superior medical schools. The bedside teaching, say the complainants, too often is left to the senior house officers. Like the Holy Ghost, say the grumblers, you can feel his presence, but the senior teacher is rarely in evidence."8 Shouldn't the student learn from the giants? And Wangensteen proposes that the teachers take an oatha commitment to teach. I hope this has been done by Fellows of the American Surgical Association. In addition, there should be commitment to protect the patient's interest by providing or closely supervising surgical care, which implies a semipreceptor educational environment. In the past, the surgeon was concerned primarily with the art and science of his profession, but today he must be concerned with another dimension-the cost of providing health care in the best interest of the patient. Proliferation of medical knowledge and research has led to increased capability, which has led to increased utilization, which when compounded with the various factors contributing to inflation has made medical care costs skyrocket. Although the physician personally receives only a small fraction of the health care dollar, he is responsible for utilization of health care capability. Therefore, he does have direct control over the largest proportion of medical costs. Quality treatment today is not tantamount to unlimited utilization of capability. Unfortunately, the availability of that capability often leads to overutilization, and this is where restraint is necessary if costs are to be controlled. Since quality of care is not evaluable by the third party, MacKenzie" suggested to physicians in the United States that they become deeply involved in order to obtain cost control along with high-quality health care. In addition, he said, "Governments will also attempt to arrange rationing unacceptable to individual patients and patients' families by making the decision appear to have been made by health-care providers [physicians]' '14 -another reason why the physician should become deeply involved in deciding the future system of health care delivery. Without question, we do overutilize our capability and add to costs by not properly using the knowledge known to us in evaluating a clinical situation. We un-

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fortunately practice "defensive medicine," ordering tests and sophisticated examinations because they are available, often in the guise of medical education. Careful evaluation of historical and physical findings in the light of a body of knowledge and known facts will often make further testing in a clinical situation unnecessary. This in part is the art of surgery and the use ofjudgment based on experience. And this is where the student can learn most in a semipreceptor or a close studentteacher arrangement. Unfortunately, the medical profession has been forced into malpractice considerations, which bypass the use of sound medical judgments. All this adds to cost. The overuse of x-ray, laboratory and specialized services-whether routinely or in the evaluation of a clinical situation-when the needed information can be obtained with available data is inexcusable. Obtaining the whole gamut of "routine" studies as an educational exercise for a student is a questionable procedure indeed. The best educational experience is not only to learn when a study is appropriate but also to know when it is not needed in the evaluation of a clinical situation. Knowledgeable and judicious use of services in providing quality care at a minimum cost is the responsibility of the surgeon, and there is no need to order "the book" to provide the best of care for the patient or for educational purposes. Each test ordered should contribute to, not necessarily corroborate, the diagnosis, or it should provide essential information needed by the surgeon for the proper management of the patient's problem. Government, industry and labor all agree that health care costs too much. It does, but with conscientious leadership by the medical profession, costs can be controlled. If others are to do it, as has been demonstrated elsewhere, costs will not be controlled, quality of care and accessibility to it will deteriorate, and the patient will suffer. The physician should not let this happen. The surgeon is entitled to a satisfactory income from his practice to achieve an acceptable standard of living for him and his family and to secure the future beyond the period of active practice. He should not, however, profit beyond that from the care of the sick or the well. Compared with the average college graduate, the physician earned less in 1976 than in 1970. The dollar brought seven times as much in 1954 as it does in 1979, yet costs of medical and surgical fees have increased only 200-400%. Costs of related items and the costs of living have increased considerably in the past 25 years-malpractice insurance 5000%, rent 600%, equipment 2000%, automobiles 500%, groceries 600o, and electrician and plumber fees 500-600%. The surgeon hardly needs to apologize for a reasonable income.3 Excessive fees and incomes, however, should be condemned.

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Dr. Will said, ... monies which should accumulate over and above the amount necessary for a living under circumstances which would give favorable conditions to work and to provide reasonably for our families, would interfere seriously with the object that we had in view [of providing quality treatment to the sick regardless of economic or social position]. Money is so likely to encourage waste of time, changing of objectives in life, living under circumstances which put one out of touch with those who have been life-long friends, who perhaps have been less fortunate. How many families have we seen ruined by money which has taken away from the younger members the desire to labor and achieve and has introduced elements into their lives whereby, instead of being useful citizens, they have become wasteful and sometimes profligate.13

And he remembered that any fund that had grown beyond his and his associates' expectations or needs had come from the sick and that ". . . we believed that it ought to return to the sick in the form of advanced medical education, which would develop better trained physicians, and to research to reduce the amount of sickness." Certainly, if the surgeon held to the goal that he should not profit beyond the needs of his practice, family and the requirements of education and research in the care of the sick, his income from patient care would always be reasonable and he need not apologize for it. Donald C. Balfour perceived that Dr. William J. Mayo and Dr. Charles H. Mayo made every effort to lessen the emotional, economic and physical burdens of the patient. That is, no patient was ever refused treatment, and all patients were accorded the same treatment regardless of economic or social position. I do not want to preempt the Committee on Issues of the American Surgical Association, but I would like to identify areas in which the surgeon can be a positive force in cost containment:

1) The surgeon should encourage preoperative evaluation on an ambulatory basis. 2) He should be constantly aware that the simple availability of tests creates demand for their use and encourages repetition, and he should order them or supervise those persons ordering them so that they will be requested only when they are essential to patient care. 3) Educational programs should stress not only the need to order tests and consultation when indicated but also the need to desist from ordering them when they are not necessary or are superfluous. Surgeons, students

271 and house staff should be made cost conscious in all areas of practice. 4) When feasible, surgeons should consider outpatient or office surgery as an alternative to inpatient surgery, if it does not detract from the quality or safety of patient care. 5) As the surgeon makes hospital rounds, he should daily ask the question, "Is continued hospitalization necessary from the medical or surgical standpoint?" Only factors related to the medical or surgical wellbeing of the patient should be considered. Continued hospitalization should not be considered for the convenience of the patient or family or for other reasons. 6) The surgeon should periodically review total hospital patient charges to keep himself sensitive to costs.

7) Operating room use is costly-the facility should be used efficiently. Operations should be done with dispatch consistent with safety, and effective utilization should be promoted. 8) Surgeons should take time to participate in cost containment, utilization and other committees of the hospital. 9) Surgical fees should be kept at a reasonable level and increased no more than the percentage increase of the gross national product. Surgeons should speak out against unjustified and exorbitant fees and unnecessary consultations. 10) Surgeons individually or through their associations should participate in educational efforts to inform the public regarding surgical care and costs and unreasonable charges. 11) Surgeons or their associations should work closely with third parties to develop insurance programs that include incentives to reduce overutilization of health care services. 12) Surgeons should seek out alternatives to the unstructured fee-for-service compensation system and to determine whether there are more effective alternatives-those that would not alter the doctor-patient relationship and quality of care and still provide the surgeon a reasonable return for his contribution to health care. If the surgeon considers his patient first-his health and his social and economic well-being-irrespective of the administrative structure of health care delivery, he can take pride in his profession, and the best of men will enter it. The patient will respond with his loyalty and support. Albert Einstein said, How extraordinary is the situation of us mortals! Each of us is here for a brief sojourn; for what purpose he knows not, though he sometimes thinks he senses

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it. But without going deeper than our daily life, it is plain that we exist for our fellow man-in the first place for those upon whose smiles and welfare all our happiness depends, and next for all those unknown to us personally but to whose destinies we are bound by the tie of sympathy. A hundred times every day I remind myself that my inner and outer life depends on the labours of other men, living and dead, and that I must exert myself in order to give in the same measure as I have received and am still receiving.6 Finally, I would like to quote from Dr. Will's response when he was honored by the American Surgical Association on his seventieth birthday at the meeting of the Association in 1931, held in San Francisco. The quotes are philosophic but very appropriate and in many respects the embodiment of the ideals of the American Surgical Association. This, then, is Doctor Will speaking in 1931:15 Mr. President and Fellows of the American Surgical Association: Your greetings on this seventieth birthday of mine repay me for living long enough to have it. The day in my thirties when I was elected to the American Surgical Association was the proudest day of my professional life. . . . In this connection, I wonder whether it would be not wise for the Association to choose for its Fellows more men in the thirties, with the idea of stimulating them to do their best.... The most important factor in what I may have accomplished . . . [is] my association with my brother. Something more than four years younger, Charlie has stimulated me by precept and example, and our association has been unique not only in the love and confidence we have for each other, but in having made an opportunity for two men to work as one and to share equally such rewards as have come. Even to this day, not only have our fraternal contacts been maintained, but also our habit of having a common pocketbook, in which each has wanted the other to have the greater share. And with due regard to the statement of a truth, my brother, Charles H. Mayo, is not only the best clinical surgeon from the standpoint of the patient that I have ever known, but he has that essential attribute of the true gentleman, consideration for others. The years have come upon me so easily and so rapidly that I can look back on each and every one of them without regret, and I feel no older now than I did when I came into this Association. As I have watched older men as they have come down the ladder, as down they must come, with younger men passing them, as they must pass to go up, it so often has been an unhappy time for both. The older man is not always able

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necessity or perhaps the justice of his descent and resents his slipping from the position that he had held, instead of gently and peacefully helping this passing by assisting the younger man. What pleasure and comfort I have had from my hours with younger men! They still have their imagination, their vision; the future is bright before them. Each day as I go through the hospitals surrounded by younger men, they give me of their dreams and I give them of my experience, and I get the better of the exchange.

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Before stopping my operative work I visited the clinics of the younger men, and I was convinced that the older man unconsciously loses something of handicraft, something of ready response to operative emergencies. When this became plain to me I was happy to turn, in the interest of the profession that I love so well and of the patients who had been my first thought, from an active surgical career to that of surgical advisor, that I might give to the younger surgeons such of value as I had, and to the patient the benefit of my experience. ... As I see the younger men picking up the torch and carrying it on, I realize that scientific truth which I formerly thought of as fixed, as though it could be weighed and measured, is changeable. Add a fact, change the outlook, and you have a new truth. Truth is a constant variable. We seek it, we find it, our viewpoint changes, and the truth changes to meet it. There are many recompenses in a seventieth birthday. I look through a half-opened door into the future, full of interest, intriguing beyond my power to describe, but with a full understanding that it is for each generation to solve its own problems and that no man has the wisdom to guide or control the next generation. It is a comfortable feeling, to be interested in what is to happen, but in bringing it about to be in no way responsible. Dr. Mayo expressed faith in the future, in constant search for the truth, in the importance of a close relationship between teacher and student and in a constant concern for the patient. Although as surgeons we should work with others toward achieving the best administrative system of health care delivery, we must remember above all else our responsibilities as physicians to all patients and to society. As members of the American Surgical Association we should remain the leaders of surgery, taking unto us the young and being willing to see them surpass us and attain new heights but giving them the best we have, melding together the art and the science of the practice of surgery for the benefit of the patient, adding a new

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stroke to the painting and realizing that it will be more complete in their day than in ours, but never finished. Again, to the Fellows of the American Surgical Association, my thanks to you for the greatest honor of my professional career: to have served as your President this year. References 1. Adams, H. B.: Cited by Sabiston, D. C., Jr.: Presidential Address: Alfred Blalock. Ann. Surg., 188:255, 1978. 2. American College of Surgeons: Statements on PrinciplesIl. Principles of Qualifications for Fellowship. Bull. Am. Coll. Surg., 60:10, 1975. 3. Davis, F. A.: Why I Had to Raise My Fees. Private Practice, p.7, February, 1979. 4. Davis, L.: Why the Declining Census in University Hospitals?

(Editorial) Surg. Gynecol. Obstet., 136:785, 1973. 5. Dunphy, J. E.: Reflections. Contemp. Surg., 10:42, 1977. 6. Einstein, A.: The World as I See It. New York, CoviciFriede, p. 237, 1934. 7. Eiseman, B.: Surgery's Greatest Challenge (Editorial). Arch. Surg., 112:1029, 1977.

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8. Erlik, D.: Is Technical Dexterity Still Important in Modern Surgery? (Editorial) Isr. J. Med. Sci., 9:3, 1973. 9. Flexner, A.: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. New York, Carnegie Foundation for the Advancement of Teaching, 1910. 10. Hall, D. P.: The Surgery of Hesitation (Editorial). Am. J. Surg., 110:360, 1965. 11. Johnson, V.: Origins and Development of the Mayo Foundation: Presented to Rochester Chamber of Commerce and Service Clubs, Rochester, Minnesota, March 19, 1964. 12. Letter from Dr. W. J. Mayo to Dr. John B. Roberts, President of the American Surgical Association, May 26, 1921. 13. Letter to the University of Minnesota from Dr. William J. Mayo, February 15, 1934. 14. MacKenzie, W. C.: The Canadian Health System: Discontent Among the Ranks. Bull. Am. Coll. Surg., 64:8, 1979. 15. Mayo, W. J.: Seventieth Birthday Anniversary of William J. Mayo. Ann Surg., 94:799, 1931. 16. Schlicke, C. P.: American Surgery's Noblest Experiment. Arch. Surg., 106:379, 1973. 17. Simon, W. E.: A Time for Truth. New York, McGraw-Hill, p. 22, 1978. 18. Wangensteen, 0. H.: Teacher's Oath (Letter to the Editor). J. Med. Educ., 53:524, 1978.

Presidential address: the unfinished painting.

ANNALS OF SURGERY September 1979 Vol. 190 No. 3 0, gz Presidential Address: The Unfinished Painting OLIVER H. BEAHRS, M.D. DR. MuRRAY, members o...
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