Portal de Periódicos da CAPES

Presidential address: SUS — SOS?

1998; Elsevier BV; Volume: 124; Issue: 2 Linguagem: Inglês

10.1016/s0039-6060(98)70111-4

1532-7361

Keith D. Lillemoe,

Radiology practices and education

It has been an honor and a privilege to serve as president of the Society of University Surgeons (SUS) for the last year. I am deeply indebted to each and every member for their support and efforts on behalf of the Society. Although the title of my address might suggest otherwise, I believe that the SUS is the premiere society for academic surgeons both young and old. This Society has a long and rich history and, I believe, a bright and promising future. A standard component of most presidential addresses is a short introduction used to attract the attention of the audience. The topic may have a historical perspective, a literary theme, or another topic of general interest to the listeners. In my case, I have chosen my personal love — sports. I would like to take you back to the year 1953. A new team, the Baltimore Colts, was beginning to play in their state-of-the-art football facility, Memorial Stadium. Their league, the National Football League (NFL), was still in its relative infancy with limited popularity. But this team and its players soon became the love of a city. Memorial Stadium, with its raucous sellout crowds, became known as the “world's largest insane asylum.”1Steadman JF From Colts to Ravens. Tidewater Publishers, Centreville (MD)1997Google Scholar The 1958 NFL championship game played at Yankee Stadium is considered by many to be the “greatest football game ever played.”2Litwin M. It's just not the same.Sports Illustrated. 1996; 85: 106-119Google Scholar This game, in which the Colts beat the New York football Giants in overtime for the league championship, may be the single event that led to the tremendous current popularity of professional football. In a roundabout way, the Colts may get credit for making the Super Bowl what it is today. After 2 years of nonacceptance and minimal fan interest, the underdog New York Jets of the American Football League (AFL) led by Joe Namath pulled an upset of the heavily favored Colts in Super Bowl III. Although the team remained successful, winning the Super Bowl in 1971 and routinely reaching the playoffs into the next decade, things began to deteriorate. New ownership soon became unhappy with the aging stadium and the city's support. Constant threats to relocate the franchise combined with losing teams and everchanging personnel led to dwindling interest, with most games in the early 1980s played with attendance much less than 50% of capacity. Perhaps the single greatest insult to the franchise came at the 1983 NFL draft in which the Colts, by having the worst record in football, earned the right to select the number one pick. But the obvious choice, quarterback John Elway, refused to come to Baltimore, prompting his trade to Denver. Finally, in the middle of the night on March 28, 1984, the Colts (lock, stock and barrel; helmets, pads and history) left Baltimore via Mayflower moving vans, moving to Indianapolis and ending a long and great tradition of football in that proud city. Now where does this story lead with respect to the SUS and a presidential address? I see a close similarity between the Baltimore Colts and the SUS. Like the Colts, the SUS has a long and rich tradition dating back to its origins in 1938. Like the Colts, the SUS has become the leader of academic surgery and serves as the so-called model franchise to which all other surgical organizations are compared. Like the Colts, the SUS has had its share of superstars. Similarities between Unitas, Donovan, Berry, Moore, and Bubba Smith can be drawn with Sabiston, Polk, Harken, Baker, Roslyn, and Dunn. Like the Colts in the early l980s, the SUS also faces challenges, many of which are beyond our control. Our members, many of whom are both scientific and clinical superstars, are being pressured to assume larger clinical roles to support the financial well-being of their departments. These expanded clinical responsibilities hurt the organization by threatening the basic scientific investigations for which the meeting of this organization has served as the mouthpiece for the best of surgical research. Furthermore, the meeting is also threatened because attendance may provide a double disincentive for the young academic surgeon. This disincentive includes both significant meeting expenses (travel, registration, and hotel) and time away from clinical practice, both increasingly significant problems for departments of surgery and their faculty. Demands at the home institution or activities of other national organizations may eat away valuable meeting time, even for those attending. Many members, including members of the Executive Council and committee chairs and representatives, arrive late, see their paper presented or give their commentary, fulfill their duties, and then depart well before the end of the meeting, leaving the talks on Saturday morning sparsely attended and showing little or no support for the residents' meeting, which represents the future of American surgery. I contend that it is the meeting of the Society that is the best reflection of the strength and vigor of an organization. The assembly of the members and the sharing of knowledge of surgical science are the “Super Bowl” of a surgical organization. If our meeting is no longer an attraction, membership in this Society may soon no longer be important. Membership in the SUS has been an important rung on the academic ladder for most university surgeons. But how much longer will membership, which for some means only a single line on a curriculum vitae, be important enough for future John Elways to choose to belong to this organization? As opposed to most of the presentations at this meeting, data are not usually part of a presidential address. I believe that in this specific case, however, if I am to make an argument in favor of change, I must provide proof, and therefore data, to substantiate my points. First, is there a problem with the SUS? The available data3Society of University Surgeons Society administrative records and minutes. 1989-1998Google Scholar would certainly suggest that if not a problem, there is a disturbing trend. The total attendance at the annual meeting for the last several years is shown in Fig 1. Starting with the l989 50th anniversary meeting, there has been a continued decrease in attendance. Certainly geography and other factors may play a role in this trend, but I would also remind you that these numbers represent all meeting registrants. Like no-shows for a professional football game, I would estimate that the number of attendees present for the entire or even most of the meeting would likely be far less. The number of abstracts submitted for consideration by the program committee is shown in Fig 2, with a similar decreasing trend reaching a nadir this year with almost 100 fewer abstracts than submitted for the Denver meeting 3 years ago. There are several theories contributing to this trend. First, the obvious – a lack of interest in presenting at the meeting in general or at a specific location of the meeting, preferring rather a regional or subspecialty meeting. But a more likely explanation may be that many members because of lack of funding, protected time, or interest are not performing the basic research that almost exclusively makes up the bulk of the scientific program. Are these trends exclusive to the SUS? I have analyzed meeting attendance during the last 4 years for 9 other surgical societies including specialty societies such as for trauma, gastrointestinal, thoracic, and vascular surgery, surgical infection, and surgical education (Fig 3, data provided by association secretarial and administrative offices). The prestigious American Surgical Association, our so-called little sister organization, the Association for Academic Surgery (AAS), and one regional surgical organization, the Southern Surgical Association, are also included. My interpretation of this figure would be that overall meeting attendance has been fairly stable, with slight fluctuations likely reflecting local meeting site. The only significant trend is increased attendance at specialty societies, perhaps reflecting members' appreciation for the opportunity to share both clinical and research ideas with people of similar interests. Total abstract submission for 4 of these societies is shown in Fig 4. Overall, the data again suggest a stable pattern. I would specifically like to point out the data from the AAS, with its higher rate of abstract acceptance, parallel sessions, and even poster sessions that has not shown the decline seen with the SUS in recent years despite a program that is similar with respect to a basic science agenda. Finally, the surgical organization equivalent of the NFL draft — applications for new membership in the SUS (Fig 5). In 3 of the last 4 years, the number of applicants for active membership has only minimally surpassed the number of vacancies created by members moving into senior status. This year's number of applicants represents the lowest total in recent society records. In summary from these data, I believe that there is some evidence to raise concern about the strength and future of this organization. For a surgical society, like a department of surgery, a corporation, or even to some extent an individual, to remain successful, the organization must perform both self-assessment and outside external review. To accomplish a self-assessment, I went directly to the active membership of the organization via a questionnaire. Unfortunately, of the 203 active members who received the questionnaire, the response was less than optimal, with only 89 respondents for a total of 44%. I initially tried to find out why members attend the SUS annual meeting. The chance to interact with friends and colleagues was the most commonly cited reason for attending (72%). Enjoyment of the scientific program was a close second as a reason for attending listed by 66% of the respondents. Forty-nine percent of individuals said that they attended because they believed it was “necessary”, whereas 46% attended because they are either involved with or would like to be involved with society activities such as committees or officer positions. I then asked the membership for suggestions on how to improve the annual meeting (Fig 6). The most commonly cited response noted by 60% of the group was to add more clinical papers to the scientific program. Moving the meeting to a Saturday/Sunday time period was suggested by 49% of respondents, whereas 45% wanted a change in format to include parallel sessions. Holding the meeting at a site with a warmer climate (34%), reducing registration fees (29%), and an expanded role for panels and symposia (24%) were also listed. Finally, I attempted to get a sketch of the current membership with respect to their primary focus. Of the 89 members who returned their questionnaires, 49% stated that their primary focus was clinical surgery, whereas only 25% cited basic research. Only one person (1%) cited surgical education as a primary focus. Twenty-two respondents, or 25%, listed two or more of these activities. I next surveyed the last 20 presidents of the SUS. Eighteen (90%) of the 20 past presidents responded to my questionnaire. Of the 18 responding, 11 individuals (61%) still regularly attend the meeting. Their reasons cited for attending include “enjoy the scientific program,” “to support faculty and staff presenting papers,” and “to support the organization.” All seven individuals who do not regularly attend cite “too many other obligations” as their reason for not attending. Fifteen (83%) of the 18 responding past presidents believe that the status of the organization has not changed since their term as president, whereas three individuals (17%) believe that the Society is of a lower status than when they were president. Fourteen (78%) of the 18 past presidents responding predict that the SUS will remain a “strong and important organization for young academic surgeons in the future.” Six individuals (33%), however, are concerned that the Society may become less important as time and financial support for basic research become limited. Finally, although 50% of the past presidents believe that the Society and the annual meeting represent the mainstream of current academic surgery, six individuals (33%) believe that the meeting has become too research oriented and 13 individuals (72%) believe that the program should be broadened to include more of a balance between research and clinical papers (Fig 7). Finally, I sought the opinion of 40 current surgical chairs, all of whom are senior members of the Society. Thirty-four (85%) of the 40 chairs responded. Although 79% of the chairs encourage their junior faculty to seek membership in the SUS, only 65% believe that membership is very important to the faculty member's career development, and 35% believe membership is only somewhat important. The majority of the chairs (59%) believe that membership in the SUS is less important than 10 years ago. Sixty-eight percent of the chairs favor a broadened program for the annual meeting to include more clinical papers, and 50% suggest expanding the Society membership (Fig 8). Finally, a clear majority of the chairs (79%) believe that the expanding demands on junior faculty have made or will make the SUS a select society of surgical researchers not typical of most surgical faculty. As part of any good presidential address, I must end with recommendations. The charge is left to my successors to implement or ignore, whatever is their choosing. First and foremost, I offer an idea that is not new for this Society, but I believe it clearly reflects the current mood of the membership: to broaden the program to meet the interests of the Society. This organization will not survive if only a handful of members understand, can discuss, or find interest in the majority of the papers presented, regardless of how good the science. I believe that the Society has already made a significant step in this direction by including the new category of “Clinical Trials and Outcomes” to this year's program. I believe that the quality of the papers presented and their acceptance by the audience reflect the wisdom of this decision. Surgery does not need another forum for large retrospective clinical series, but I encourage the membership to consider this Society's meeting for presentation of their best prospective clinical trials and innovative clinical outcomes studies. Second, I believe that the Society should give consideration to parallel activities. This change should not be to the extent of our residents' meeting, with eight simultaneous sessions, but rather a careful grouping of selected papers that, although they may cross subspecialty lines, share a common theme. This step may allow for inclusion of a greater number of papers and therefore more membership participation in the meeting. There must, of course, be limits with this expansion including only papers of the highest quality. The level of paper acceptance, however, for this meeting was only 22%, which I believe allows significant room for expansion of the program. The move to an expanded program may jeopardize our relationship with the journal, Surgery , and may necessitate elimination of the policy for mandatory submission of all manuscripts for publication. Although I strongly support the relationship with Surgery and believe most presenters will continue to publish their papers as in the past, there are advantages to a change in this policy. I am sure we are all well aware that some laboratories, hoping to impress study sections or promotion committees, may hold back their “best work” from the SUS, hoping for publication in Science , Nature , or the Journal of Clinical Investigation . The elimination of mandatory publication may allow for presentation of some of this work at the annual meeting and lead to an actual improvement in the quality of science presented before the Society. Furthermore, parallel sessions may eliminate inclusion of the published discussion of papers, which in many cases represents a scripted, wordy, formal soliloquy that stifles the free exchange of scientific ideas for which this Society has become famous. If extra time is created by parallel sessions, the opportunity might exist to allow mini-seminars on specific topics or invited commentaries of general interest to the membership. A career achievement presentation by a senior member chosen by the Program Committee to both honor a lifetime of success in academic surgery and provide a stimulus for those members being misdirected by the current state of academic surgery could be considered. Expansion of the popular presentations of the Education and Social and Legislative Issues Committees could also be a benefit of parallel sessions. A change in the days of the week in which the meeting is held should also be considered. Why the Society must meet from Thursday to Saturday is unclear, especially since by Saturday morning, attendance is usually quite sparse. Meeting through the weekend would decrease airfares for the members and decrease the time away from clinical and administrative duties. I do not favor a change in the current policy with respect to meeting site selection. I believe that hosting the SUS is a great opportunity for a department that should not be denied on the basis of latitude or geography. However, I urge that future executive councils carefully consider factors such as access for members and transportation and cost considerations in selecting host institutions. My most difficult recommendation concerns membership. I spoke earlier about my concerns that future academic surgeons may not wish to join the SUS. My hope is that, with the changes I have proposed, this will not be a problem, and that applications will continue to be offered by individuals not wishing to simply add another line to their curriculum vitae, but because of a genuine interest and desire to participate in this Society. I have heard on more than one occasion that some individuals believe that the purpose of this society is to “keep other people out.” I sincerely believe that this is not the case. The restriction of membership to 250 active members is probably archaic. Data provided by the Association of American Medical Colleges has shown that the number of full-time surgical faculty in American medical schools has risen from 3332 in 1977 to 7519 in 1997, an increase of over 125%.4Association of American Medical Colleges Faculty Roster System, 1998.Google Scholar Yet SUS continues with the same active membership limitation set by the Executive Council in 1970. Entry into this Society should be based on criteria of excellence as a member of the academic surgical community and not based on a number of positions available in the organization. Applicants should be considered on the basis of their overall contributions to all components of academic surgery by current criteria including clinical productivity and research and surgical education, and not on a set number of papers or dollars of National Institutes of Health funding. To best accomplish this policy, I would suggest that the SUS follow the policy of the American Surgical Association, with a separate membership committee devoted to careful evaluation of the candidates without politics and institutional biases. Finally, I would like to propose that although entry into the organization should still be limited to individuals younger than 45 years, active membership in this Society, including the right to hold office, should be extended to age 50. Advanced degrees, extended periods of laboratory research during residency, and clinical fellowships have become so common for academic surgeons during the last decade that the age of many current applicants has increased to the point that many individuals are approaching senior status at the time that they are ready to apply. During the last 3 years more than 30% of new members have been 43 years of age or older at the time of entry into the organization, leaving no more than 2 years of active membership in the Society (Fig 9). I close at this point, leaving you with a wide range of proposals for future executive councils to consider. I would hope that my suggestions are viewed not as a criticism coming from a person who perhaps does not have the basic science credentials of other members of this organization, but rather from someone who has now served the Society for 4 years. These ideas were formulated as I quietly observed the development of obvious threats arising from both outside and within a society for which I have tremendous respect. I realize that to many in this audience these changes may be considered heresy and my perceptions unsubstantiated. If I am wrong and this Society continues to flourish, no one will be happier. But if I am right and these warnings are not heeded and appropriate changes are not made, the equivalent of the Mayflower vans that broke the hearts of the Colts fans in Baltimore may soon be seen again. SUS — SOS? — Save Our Society. This title was posed as a question. The answer remains unknown. But I believe that the membership and leadership of the Society of University Surgeons can, with the proper steps, make the answer a resounding “NO”! I thank Mary Samokar for providing data from the Society records.