Portal de Periódicos da CAPES

Da Vinci and the Penrose drain

2003; Elsevier BV; Volume: 38; Issue: 3 Linguagem: Inglês

10.1053/jpsu.2003.50093

1531-5037

Arnold G. Coran,

Medical History and Innovations

Being chosen to serve as President of the American Pediatric Surgical Association is one of the greatest honors any pediatric surgeon can receive. Therefore, I want to thank you, the members of this organization, for electing me to this office and for affording me this great privilege and opportunity. I want to acknowledge several people to whom I owe much for helping me and nurturing me in my career. At the top of the list is my wife, Susi. She is the reason I am here today. Without her support in promoting my career to the sacrifice of her own career and without her devotion to the task of bringing up our 3 wonderful children, none of my accomplishments would have been possible. I want to thank our 3 children and 7 grandchildren for their love, understanding, and support. Finally, I want to thank my colleagues, residents, administrators, nurses, and secretaries who have worked with me over these past 32 years. I would not be here today without them. Along the way, all of us have had mentors who have been major forces in determining the direction of our careers. I have been fortunate to have had many such individuals; however, 3 have been especially important to me. The first is my father, Charlie Coran, a self-educated, very bright man, who never had the opportunity to go to college but, nevertheless, encouraged me to go to college and graduate school. When I was 11, he taught me Latin and read Caesar's Gallic Wars with me. When I was 60, he showed me how to die with great dignity. This is a picture of my mother and father after 55 years of marriage. Next is Francis D. Moore (Fig 1), one of the most brilliant American surgeons of his generation, who inculcated in me the excitement of surgery and the need to take a complex clinical problem to the laboratory and study it.When, as a third-year medical student, I was not sure whether I wanted to become an internist and biochemist or a surgeon, I went to his office with my dilemma. With his incredible use of the English language, Dr Moore said, “Arnie, a surgeon is merely an internist who has learned to dissect along tissue planes.” Although, he was disappointed initially in my choice of pediatric surgery as a career, he never slackened in his support of me over all these years. Unfortunately, Dr Moore died this past year. Robert E. Gross (Fig 2), shown here in 1984 at a symposium held in his honor at the Harvard Medical School, a personality completely different than that of Francis Moore, taught me the importance of expertise in technical surgery and the need for a pediatric surgeon to maintain a broad base and be able to operate in many different parts of the body with equal skill.Fig. 2Photograph of Robert E. Gross, former Surgeon-in-Chief of the Boston Children's Hospital. The picture was taken in 1984 at a symposium in his honor at Harvard Medical School.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Finally, I want to single out 4 unsung heroes in our specialty, who have made many contributions to pediatric surgery, especially in the area of education of residents. The first is Arnie Colodny, who passed away last year, and who encouraged me to go into surgery as my animal surgery instructor in my third year of medical school. He taught me more about the clinical practice of pediatric surgery during my general surgery and pediatric surgery training than any other faculty pediatric surgeon with whom I worked. Next is Angie Eraklis, whom I met on July 1, 1963 at the start of my internship at the Peter Bent Brigham Hospital when he was a Senior Resident in general surgery. He helped me do my first operation, an appendectomy, and emphasized then and throughout my relationship with him as a general surgery and pediatric surgery resident, the importance of efficiency and focusing in the operating room. Unfortunately, Angie just passed away a few months ago. We will all miss him. When I took my first job in 1971 in Los Angeles, I met Jordie Weitzman, a young energetic pediatric surgeon, with excellent clinical and technical skills, who taught me how to swim among sharks and was very supportive of me during my early years in Los Angeles and my later years in Ann Arbor. Unfortunately, Jordie passed away suddenly last year. Finally, Leo Siplovich, whom I met 11 years ago, instilled in me the value of getting involved with children with surgical problems in other parts of the world. Because of all of these people and because of all of you, I am here today. When I received a call from Kathy Anderson 2 years ago indicating that I had won the election for President of APSA, I was elated. After 20 seconds, however, I broke out into a cold sweat because I knew this meant I would have to deliver a Presidential Address, and almost everything that could be said had been said by previous presidents. I decided I would not talk about managed care, reimbursement, or manpower, subjects that had been thoroughly covered previously. I struggled for a topic until I came across 2 books this past year, 2 very different books, that present a concept that has formed the basis of this address. I hope that the ambiguity of the title of this presentation will be clarified as the address proceeds. When all of us in this audience retire and look back at our careers in pediatric surgery, we are not going to ask ourselves if we improved reimbursement, if we learned how to deal with managed care organizations or HMOs, or if we learned how to bill better, rather, we will ask if we made a difference in the surgical care of infants and children, not just in our own local area, but throughout our nation and even around the world. Betty Jean Lifton published a book entitled “The King of Children” in 1988, which details the life and death of a very famous Polish pediatrician and writer, Janusz Korczak, who lived only for children.1Lifton BJ The King of Children. St. Marten's Griffin, New York, NY1988Google Scholar In 1930, at age 61, Korczak used his international prestige as an author of 5 children's books to protect deserted, abandoned, and orphaned children. Unfortunately, on August 6, 1942, he and his children were marched out of the Warsaw Ghetto to Treblinka, where they all perished in the gas chambers (Fig 3).The dignity he and his children displayed as they marched to their death was so impressive that the concentration camp guards stood at attention and rendered them honors. Janusz Korczak (Fig 4) introduced nondenominational progressive orphanages designed as just communities into Poland, founded the first national children's newspaper, trained teachers in what we now call moral education, and worked with juvenile courts defending children's rights.His books “How to Love a Child” and “The Child's Right to Respect” gave parents and teachers new insights into child psychology. Generations of young people had grown up on his books, especially the classic “King Matt the First,” which tells of the adventures and tribulations of a boy king who aspires to bring reform to his subjects but fails. This book was as beloved in Poland as “Peter Pan” and “Alice in Wonderland” were in the English-speaking world. It wasn't that Korczak glorified children, as did Rousseau, whom he considered naive; Korczak felt that within each child there burned a moral spark that could vanquish the darkness at the core of human nature. To prevent that spark from being extinguished, one had to love and nurture the young, and make it possible for them to believe in truth and justice. He is best characterized by Elie Wiesel, the recipient of the Nobel Peace Prize, as follows: “He was an extraordinary man who, until the end of his life, dreamed and worked only for unfortunate children, and lost his life hand-in-hand with the children he had tried to protect.” He further described him as a physician, educator, and writer who lived only for others. He practiced a universal humanism. He loved children. His was total, absolute love. In his most important work “How to Love a Child,” he combined his experiences and observations concerning the spiritual and practical nurturing of children, almost as if Kahlil Gibran and Dr Spock had joined forces. One of his most remarkable accomplishments was to establish a weekly newspaper called “The Little Review” in 1926. This was produced for children. Mailboxes were set up across Poland for children to submit questions and problems. He set up 12 telephones so that any child could talk, ask questions or make a complaint at any time. There were 3 editors, one adult, a boy, and a girl. Near the end of his life he was asked, “When everyone acts inhuman, what should a man do?” His reply was, “He should act more human.” When the United Nations declared 1979 “The Year of the Child,” it also named it “The Year of Janusz Korczak” to mark the centenary of his birth. Significantly enough, in that same year, it was Poland that proposed that a convention should be drafted based on a text manifestly inspired by the teachings of Korczak. The Polish convention proposed that all children shall be provided with education, social security, and health care; shall be protected from exploitation, abuse, torture, and the effects of war; and, on reaching a reasonable age, shall be consulted on any decisions involving them. These were the basis of the document entitled The Convention of the Rights of the Child, which was passed unanimously by the United Nations General Assembly in 1989. Probably the greatest statement attributed to Janusz Korczak was made by Pope John Paul II, “For the world today, Janusz Korczak is a symbol of true religion and true morality.” From my perspective, the most impressive of his writings was his “Declaration of Children's Rights” (Fig 5).2Joseph S A Voice for the Child: The Inspirational Words of Janusz Korczak. Harper Collins Publishers, London, England1999Google ScholarFig. 5The Declaration of Children's Rights by Janusz Korczak.View Large Image Figure ViewerDownload Hi-res image Download (PPT)If we were to summarize his declaration into one sentence, it would read, every child has the right to love, happiness, and health. What does this story of this outstanding human being, writer, and pediatrician mean to us as pediatric surgeons and members of APSA? It means, to extrapolate Janusz Korczak's concepts, that we, as representatives of the most advanced pediatric surgical care in the world, have to utilize this expertise and skill to improve the health, specifically the surgical health of children locally, nationally, and universally. This brings me to the second book, a best seller published in 1999, entitled “The Lexus and the Olive Tree”3Friedman TF The Lexus and the Olive Tree. Farrar, Straus Giroux, New York, NY1999Google Scholar by Thomas L. Friedman, the Foreign Affairs Correspondent for the New York Times and a Pulitzer Prize recipient for his book “From Beirut to Jerusalem.” He just received his third Pulitzer prize this year. His book starts out with a quote from a full-page newspaper ad run by Merrill-Lynch on October 11, 1998 at the height of the global economic crisis. The ad read: “The World is 10 Years Old. It was born when the Berlin Wall fell in 1989. It's no surprise that the world's youngest economy—the global economy—is still finding its bearing.” The spread of free markets and democracy around the world is permitting more people everywhere to turn their aspirations into achievements. And technology, properly harnessed and liberally distributed, has the power to erase not just geographical borders but also human ones. Today's era of globalization is built around falling telecommunications costs, thanks to microchips, satellites, fiber optics, and the Internet. These new technologies are able to weave the world together even tighter. These technologies also allow companies to locate different parts of their production, research, and marketing in different countries, but still tie them together through computers and teleconferencing as though they were in one place. Also, thanks to the combination of computers and cheap telecommunication, people now can offer and trade services globally, from medical advice, to software writing, to data processing, that could never really be traded before. And why not? A 3-minute call in 1930 between New York and London in 1996 dollars cost $300. Today, it is almost free through the Internet. Globalization is not a phenomenon. It is not just some passing trend. Today, it is the overarching international system shaping the domestic politics and foreign relations of virtually every country. The globalization system is a dynamic ongoing process, involving the inexorable integration of markets, nation-states, and technologies in a way that is enabling individuals, corporations, and nation-states to reach around the world farther, faster, and deeper and cheaper than ever before, and in a way that is also producing a powerful backlash from those brutalized or left behind by this new system. The driving idea behind globalization is free-market capitalization; the more you let market forces rule and the more you open your economy to free trade and competition, the more efficient and flourishing your economy will be. Globalization means the spread of free-market capitalism to virtually every country in the world. Culturally speaking, “globalization is largely, though not entirely, the spread of Americanization, from Big Macs to i Macs to Mickey Mouse,” to quote Friedman, “on a global scale.” The symbol of the globalization era is the Worldwide Web, which unites everyone. The Cold War, which ended in 1989, was about Einstein's mass-energy equation,e = mc2. Globalization is about Moore's Law, which states that the computing power of silicon chips will double every 18 to 24 months. With globalization, the natural boundaries between politics, culture, technology, finance, national security and ecology disappear. You cannot explain one without referring to the other. Most people had never heard of the Internet in 1990, and very few people had an e-mail address then. That was just 12 years ago! But today the Internet, cell phones, and e-mail have become essential tools that many people, from both developed and underdeveloped countries, cannot imagine living without. So world affairs today can only be explained as the interaction between what is as new as an Internet Web Site and what is as an old as gnarled olive tree on the banks of the Jordan River. Globalization awakens the age-old quests for material betterment and for individual and communal identity in an era when all boundaries are disappearing. A dramatic example is an ad for Subaru Automobiles I saw a few years ago. It said: "What is an American car? It then compared a Subaru with a Chevrolet and showed that about two thirds of both cars were manufactured in Malaysia, Singapore, the Philippines, China, Mexico, Germany, the United States, Thailand, Canada, and Japan. These cars were made in so many different places that we cannot specify a country of origin. The challenge of globalization for countries and individuals is to find a healthy balance between preserving a sense of identity, home, and community and doing what it takes to survive within the globalization system. If globalization comes at the price of a country's or individual's identity, there will be a struggle and rebellion. What caused the Berlin Wall to fall? The answer is 3 fundamental changes, changes in how we communicate, how we invest, and how we learn about the world. These changes were born and incubated during the Cold War and achieved a critical mass by the late 1980s when they finally came together into a whirlwind strong enough to blow down all the walls of the Cold War system and enable the world to come together as a single, integrated open plain. Today, that plain grows wider, faster, and more open every day, as more walls get blown down and more countries get absorbed. And that is why today, there is no more First World, Second World, or Third World. There is just the fast world, the world of the wide open plain, and the slow world, the world of those who either fall by the wayside or choose to live away from the plain in some artificially walled-off valley of their own, because they find the Fast World to be too fast, too scary, too homogenizing, or too demanding. A wonderful story told by Friedman in his book concerns former US Treasury Secretary Larry Summers, the current President of Harvard University. In 1988, when he was working on Michael Dukakis' presidential campaign, he was sent one day to Chicago by the campaign staff to give a talk. The Dukakis campaign assigned him a car, and it had a phone in it. He thought it was quite neat to have a phone in a car and he called his wife having no other use for it at that time. Nine years later, in 1997, as Deputy US Treasury Secretary, he was visiting the Ivory Coast in West Africa. As part of his visit, he had to inaugurate an American-funded health project in a village up river from the Capital Abidjan. The village could only be reached by dugout canoe. On his way back from the village, as he stepped into the dugout canoe to go back down river, an Ivory Coast official handed him a cell phone and said “Washington has a question for you.” Summers' adventure highlights the changes that have occurred since the Cold War during the era of globalization; these are the changes in how we communicate with each other. These changes are really what Friedman calls “The Democratization of Technology,” and it is what is enabling more and more people, with more and more home computers, modems, cellular phones, cable systems, and Internet connections to reach farther and farther into more and more countries, faster and faster, deeper and deeper, cheaper and cheaper than ever before in history. The democratizing of technology is the result of several innovations that came together in the 1980s involving computerization, telecommunications, miniaturization, compression technology, and digitization. Advances in microchip technology have resulted in computing power doubling roughly every 18 months over the past 30 years, whereas advances in compression technology mean that the amount of data that can be stored on a square inch of disk surface has increased by 60% every year since 1991. Meanwhile, the cost of that storage capacity has fallen from $5 a megabyte to 5 cents, making computer power stronger and more accessible everyday. Innovations in telecommunications have steadily brought down the cost of a phone call and data transfers, while constantly increasing the speed, distance, and amounts of information that can be transmitted on a phone line, cable, or radio signal. Not only can you call anywhere cheaply, you can call from anywhere cheaply, including from your laptop, your mountaintop, your airplane seat, or the top of Mount Everest. This is possible because innovations in miniaturization have steadily reduced the size and weight of computers, phones, and pagers. Now they can be taken to more far-flung places and afforded by people with less income. Thus, these innovations have made it possible for hundreds of millions of people around the world to get connected and exchange information, new knowledge, money, family photos, financial trades, music, and television in ways never witnessed before. Among these hundreds of millions of people are hundreds of millions of children, whose parents want the best care for them, including the best surgical care. Former NBC News President Lawrence Grossman neatly summed up this democratization of technology as follows: “Printing,” he said “made us all readers, Xeroxing made us all publishers, television made us all viewers, digitization makes us all broadcasters.” This democratization of technology is how Thailand, in 15 years, went from being a primarily rice-producing country to being the world's second-largest producer of pick-up trucks, rivaling Detroit, and the fourth-largest marker of motorcycles. Selectronic, a 4-year old firm in New Delhi, India, types operative notes, progress notes, and referring letters dictated by physicians at the University of Michigan on a telephone in our offices. If we take the democratization of technology with the resultant provision of services around the world through networks like the Internet to reductio ad absurdum, why not outsource governments. You could outsource commando operations and border guard jobs to the Russians. The Indians could keep your country's books and the Swiss could run your country's custom service. The Germans could run your country's banks and the Italians could design all your shoes. The British could run all the high schools and the Japanese could run the elementary schools and our trains. And maybe, the United States could lead and manage health care delivery to other countries because we possess the most advanced medical system in the world today. Obviously, this may not be practical or acceptable to physicians in other countries, but the concept does suggest that the major advances in medicine occurring rapidly in the United States during this past decade of globalization through high technology discoveries need to be made available to patients throughout our country and the rest of the world. One might ask: “Did the tragedy of 9-11 negate the concept of globalization?” The answer is emphatically, “no.” Granted, it was the availability of telecommunications and computers that enabled the terrorists to carry out their dastardly acts, and it has been this same technology and globalization that has allowed the United States to form its coalition with other nations and defeat the Taliban and the Al Quaeda. So globalization is not a passing fancy or a transient phenomenon, it is what exists in the world today, and it is here to stay. In 1999, the world's population passed the 6 billion mark. An estimated one third to one half of our world's population, 2 to 3 billion people, still lack basic surgical care. Nearly one half of these 2 to 3 billion people are children under 15 years of age, especially in the underdeveloped countries. In India, with a population of over one billion people, there are over 400 million children less than 15 years of age. A similar number exists for China. In Ethiopia, Tanzania, and Mozambique, there is 1% of the number of surgeons that exist in the United States and Canada. In Pakistan and Eastern Africa, 90% of women requiring cesarian section do not receive this essential operation. Many of these women and babies die from rupture of the uterus. Many patients still are dying of untreated acute appendicitis 115 years after Fitz and McBurney separately described its surgical care. Without a doubt, there is a desperate lack of surgical, especially pediatric surgical care, in much of the world. For the past century, churches and missionary societies have initiated medical and surgical care and training facilities in many parts of the world and continue to do so. But the needs are growing everywhere. Surgeons from the United States and developed countries can help through encouragement, advice, planning, and direct participation. Although governments and health agencies from developed countries can help, strong input from surgeons is necessary; otherwise, these agencies may not do the right thing. These concepts are applicable especially to the microcosm of pediatric surgery. Whatever systems may be devised for the varied needs of different regions, the following principles should be followed.4Blanchard RJW Merrell RC Geelhoed GW et al.Training to Serve Unmet Surgical Needs Worldwide.Bull Am Coll Surg. 2001; 193: 417-427Abstract Full Text Full Text PDF Scopus (19) Google Scholar (1) Surgical care must be effective and safe. (2) Surgical care must be widely accessible, either by transport systems or by regional centers. (3) Surgical care must be affordable within the local and national capacity. (4) Surgical care must be appropriate for local situations: infrastructure, such as supply of electricity, communications, available laboratory and pharmaceutical capacity, have to be considered in planning. (5) The surgical care system must be locally sustainable. Repeated provision of services by external visiting surgical teams can be extremely helpful but should not take the place of permanent and affordable local programs. Many might argue that developing countries need preventative care not curative care such as pediatric surgery. But acceptance of preventative care by a population rests on the credibility won by curative care. In this “Golden Age of Surgery,” the gap is widening between the haves and have-nots in all parts of the world. More importantly, the have-nots know what they do not have today because communication via telephone, television, and the Internet has made patients, especially parents of sick children, acutely aware of what is available for the surgical care of their children in the developed world. How many of you in this audience have received e-mails from parents in undeveloped countries asking for advice on what to do with their child with Hirschsprung's disease or esophageal atresia. In fact, one often even receives these types of e-mails from parents in other developed countries. Globalization working. These parents want the best for their children, not just the best that is available in their local community, but the best that is available in the world. It is globalization that has made them aware of what is the highest quality of surgical care for their children. It is their inability to access this type of quality care that frustrates them and can even lead to resentment against the developed nations. Therefore, if it is globalization that has allowed parents of children with surgical needs around the world to learn about the best care that is available, then it will be globalization that will allow us, American pediatric surgeons, to attempt to provide this care to as many children as possible throughout our country and the rest of the world. Because, if we return to Janusz Korczak's Declaration of Children's Rights, loved, happy, and healthy children will grow up into mature, happy, and healthy adults. It is, I believe, these future adults who will become the next generation's leaders. They certainly will be the ones to choose peace and democracy rather than violence and dictatorship; thus, in the end, make the world a better place in which to live. This is in a sense our insurance policy for a better world, one in which there will never be another 9-11. Finally, what options are available to us as pediatric surgeons to try to make a difference in the surgical care of children around the world?Travel fellowships for young surgeons from underdeveloped countries to centers in North America. Over the years these have proved invaluable. Recipients returning have encouraged and stimulated younger colleagues by sharing their experience and reporting developments in centers visited.Access to biomedical information through books and journals; but because of postage costs, which are considerable, access to the Journal of Pediatric Surgery and Pediatric Surgery International through the Internet.Pediatric surgeons from North America traveling to these countries to operate on complex problems, and to teach local general and pediatric surgeons how to do these operations (Fig 6).Organization of courses, workshops, seminars, and visiting lectureships.Provision of appropriate audiovisual teaching and learning aids through the Internet. For example, the technology is here to have pediatric surgeons anywhere watch an operation being done in America on their computer through a CD or through what is called streaming. In addition, videos of operations can be sent via e-mail.Provide a clearing house on the Internet through APSA's Web Site, which would provide information matching the needs of individual patients or doctors with the resources that North American pediatric surgeons have available to help meet those needs.Develop a program to allow finishing North American pediatric surgery residents to delay starting their jobs by 6 months or a year to travel abroad to bring the latest technology and surgical innovations to these underserved areas. Perhaps this could be supported by the APSA foundation so that these young pediatric surgeons do not have to experience any significant financial disadvantage.Develop programs to bring children from underserved regions to North America for surgical care.Maximize the use of telemedicine throughout all the pediatric surgical centers in North America for both diagnostic and therapeutic interventions.Finally, reconstitute the International Relations Committee of APSA, and encourage it to liaise with WOFAPS on all these issues. As my final act as outgoing President, I plan to organize this committee. I hope the ambiguity of the title has clarified itself throughout my address. Obviously, DaVinci is not Leonardo DaVinci but rather the most sophisticated surgical robot available today, which is available to North American pediatric surgeons and their patients, and the Penrose drain is the most primitive tool available to all surgeons throughout the world, but may be the only tool available in some parts of the world. I would like to end with 2 of my favorite thoughts.In 1967, I was a Senior Surgical Resident at the Peter Bent Brigham Hospital. At a Saturday morning Surgical Grand Rounds, I was sitting next to Joe Murray, the 1990 recipient of the Nobel Prize for Medicine, listening to the presentation of a very complex patient by Arvin Philippart. During the presentation, Joe turned to me and said: “Arnie, what a privilege we've been given to take care of such sick patients.”In 1943, Reinhold Niebuhr, one of the most famous theologians of our time, wrote: “God give us grace to accept with serenity the things that cannot be changed, courage to change the things that should be changed, and the wisdom to distinguish the one from the other.” Friends and colleagues, let's all of us make a difference and change what we can. Thank you for the privilege of the floor and the honor of being your President this past year.