November 1, 2021
Since the founding of the American College of Surgeons (ACS) in 1913, the organization’s Presidents have delivered an address describing their professional experiences and outlining their vision for the future. Each ACS Past-President offers sage advice in these addresses, often in the form of pointed aphorisms, on a wide spectrum of topics with the goal of galvanizing new Initiates and defining the goals and notable achievements of the College.
The first ACS President to address the College was J.M.T. Finney, MD, FACS, in 1913. In his address, Dr. Finney asserted that “The American College of Surgeons…stands only for the good of humanity and the uplift of professional standards of morality and education. If it does not fulfill its special mission…it is your own fault.”1,2
George Crile, MD, FACS, delivered the second address as incoming College President in 1916. After Dr. Crile’s address, no Presidential Addresses were delivered until 1919, when William J. Mayo, MD, FACS, became President of the combined ACS and Clinical Congress.
According to the ACS Archives, the address of each incoming College President was delivered at the Convocation at the end of Clinical Congress week until 1936, at which time it was discontinued. Thereafter, each President made one address upon retiring from office, until 1953. That year, the retiring President, Harold Foss, MD, FACS, delivered his Presidential Address on Monday evening, and Fred Rankin, MD, FACS, gave an address as incoming President on Friday evening. Since then, each College President has made a single address at the Convocation.2
“They weren’t always called Presidential Addresses—they were called ‘Address to the Fellowship,’ for example,” said David L. Nahrwold, MD, FACS, retired chair of surgery at Northwestern University, Chicago, IL, and coauthor of the book chronicling the history of the ACS titled A Century of Surgeons and Surgery: The American College of Surgeons—1913–2012.3 “And in the early days, they were given by a variety of people, and they focused on what the College was doing and what the College was trying to accomplish. In other words, these addresses were focused on the idea of excellence as a surgeon to try to explain to people whom this College is composed of and to differentiate surgeons from doctors who did surgery.”
“Howard C. Naffziger, MD, FACS, in one of the earlier addresses from the 1940s, titled Metamorphosis of the Surgeon, refers to it as a ‘commencement address,’” added Peter J. Kernahan, MD, PhD, FACS, a surgeon, medical historian, and coauthor of A Century of Surgeons and Surgery: The American College of Surgeons—1913–2012. “I think, similar to a commencement speech, these addresses are a way of passing on the ideals and the goals of the organization to young surgeons just entering the College.” In fact, the origin of the commencement speech harkens back to medieval times when students entered universities as apprentices and left ready to “commence” their professions.4
“From the historian’s point of view, the ACS Presidential Addresses really show us what issues people considered important at the time,” said Dr. Kernahan. “Early on, two of the biggest challenges were the state of hospitals and the hospital standardization program, and the attempt to distinguish the qualified surgeon from the unqualified surgeon at a time when the public had absolutely no way of making that distinction.”
In fact, until the late 19th century, standards of care, quality, and residency training were relatively new concepts for the surgical profession, and most surgeons operating at that time were self-taught and unsupervised.5 The creation and development of the College resulted in a professional organization that offered leadership and standards for education and practice for all providers of surgical care.
In Dr. Finney’s first Presidential Address, he describes the rationale for the formation of the College, according to Drs. Nahrwold and Kernahan. “He’s defending the College against some of the criticisms that were leveled against it at the time,” Dr. Kernahan said. “And that’s picked up again in Crile’s address and during Mayo’s address. As we go on, and it starts even by the late 1930s, you start to see people talking about some broader issues in these addresses. And certainly, by the time we get to the last 50 years, increasingly issues of government involvement in health care are a focus.”
In reviewing the ACS Presidential Addresses from the last 25 years (1996–2020), four overarching themes emerged:
This article shares a selection of notable excerpts from ACS Presidential Addresses that are tethered to these identified categories with the goal of showcasing the enduring and evolving wisdom and legacy of College leadership (see below).
In addition to the four themes of leadership, surgeon wellness, diversity and inclusion, and patient care and quality care, Dr. Kernahan said he would add “professionalism” and “concerns related to surgical specialization and the future of general surgery.”
“In the 1950s or so, the concern among specialists was that the College just represented general surgery or general surgeons. By the 1980s, there is a sense that the general surgeons aren’t really represented by the College. And so, I think that’s one other theme that is a subtext that runs throughout some of these addresses and that is historically a challenge for the ACS, to broadly represent multiple surgical specialties,” Dr. Kernahan said.
“I think leadership has been a constant [theme] in these addresses, especially as it relates to governmental affairs,” added Dr. Nahrwold. “The other constants, in my opinion, are patient care and quality of care—and, ultimately, these are the most important. These are why surgeons exist; it is why the College exists, really. It would be disappointing if a Presidential Address weren’t focused on that. I think the greatest ACS Presidential Address of all time was delivered by LaSalle D. Leffall, Jr., MD, FACS, in 1995.”
A cornerstone of Dr. Leffall’s address, Reaffirmation of Fealty—To Serve All, is patient care. In his oration, Dr. Leffall said, “There is no closer, more reverent, or more honored bond than the one that exists between surgeons and their patients.”6 Later in the speech, he asserts, “We must never forget that the object of our affection is the surgical patient.”6 “That is not something most surgeons would say, but Dr. Leffall really meant that. And, on reflection, I believe most surgeons would agree with Dr. Leffall’s statement,” Dr. Nahrwold said.
Dr. Kernahan also referenced Dr. Leffall’s 1995 speech as exemplary, as well as George F. Sheldon’s, MD, FACS, 1998 address, Professionalism, Managed Care, and the Human Rights Movement; and LaMar S. McGinnis, Jr.’s, MD, FACS, 2009 address, Professionalism in the 21st Century.
“Another interesting one is C. Jeff Miller’s, MD, FACS, 1930 address, The Doctors of Fiction—it’s the only one that engaged in literary criticism,” said Dr. Kernahan. “It’s his review of [Sinclair Lewis’s] Arrowsmith and other books and novels about doctors, which were very popular at the time.”
ACS Presidential Addresses traditionally outline the challenges faced by the College and illustrate the aspirations for the organization, all through the lens and perspective of the leader delivering the speech. With this in mind, how will the content and format of future ACS Presidential Addresses evolve in the future? In the digital age, does the formal, spoken word continue to inspire and inform members and other interested stakeholders?
“It’s always hard to try to make predictions,” said Dr. Kernahan. “But I think one contrast we have this year and last year, it’s that we’re able to get the address in an online format. I don’t know—maybe it’ll all be virtual in the future. I certainly would think some aspects of the Clinical Congress might well be running in parallel to in-person meetings, which means things like Presidential Addresses would be more accessible to a wider audience in the virtual environment.”
“The memory of these addresses is very short, so, I think that’s one context you have to deal with in these Presidential Addresses. That being said, when they are written out and when they are distributed after they’re given orally, I think they have more meaning to some Fellows,” said Dr. Nahrwold, noting that in the early days of the College, Presidential Addresses were published in Surgery, Gynecology and Obstetrics (now the Journal of the American College of Surgeons [JACS]), and later, in the ACS Bulletin.7 “Usually, these addresses are extremely well delivered, but because the thoughts are quite deep, one needs to be able to mull over these addresses in order to get their full meaning. In a perfect world, it might be best to tell people who are going to give Presidential Addresses that the most important thing that’s going to happen here is that what you say is going to be published. So, write it as if it was going to be published, not necessarily delivered before a group of people.”
Although the content and delivery platform for ACS presidential orations will continue to adapt with current-day challenges and opportunities, these presentations will undoubtedly continue to highlight the fundamental goal of the College—to serve all with skill and fidelity.
“Presidential Addresses will likely always do a couple of things,” Dr. Kernahan said. “One is they’re there to encourage engagement with the College. It’s also used by the speaker to illustrate how much change there has been over their lifetime and to let young surgeons know that similar changes can be expected over their own professional careers. The other thing is thanking mentors, which in surgery has a long tradition. We still pass on the craft and that old idea of apprenticeship. I think all surgeons remember those who taught them, even if they don’t give a Presidential Address.”
The author would like to thank Meghan Kennedy, ACS Archivist, Division of Member Services, Chicago, IL, for her perspectives on College history specifically regarding past Presidential Addresses and for her and Michael Beesley’s, ACS Assistant Archivist, help in researching and locating ACS past Presidential Addresses.
Following is a selection of noteworthy excerpts and quotes from ACS Presidential Addresses spanning the last 25 years. As previously stated, these excerpts are organized into four categories: leadership, surgeon wellness, diversity/inclusion, and patient care/quality care.
Each of these presidential addresses is featured once within one of the four categories. Reviewing and selecting these excerpts is a purely subjective exercise, as these orations cover a wide spectrum of relevant and informative topics. The purpose of these excerpts is to provide the reader with a glimpse into the perspectives of ACS leaders from the recent past.
For further examination, these and the entire list of ACS presidential orations are available here via the ACS Archives.
The American College of Surgeons floats and sails on a ship that is more akin, allegorically, to that of the late Jacques Yves Cousteau’s Calypso, plying the seas in order to expand knowledge and preserve the meaningful environment: an altruistic goal, rather than that of a tanker carrying a commodity to enrich the owner. The panoply of the College’s meaningful contributions to society transcends all surgical specialties. The American College of Surgeons is, in essence, the cement substance that brings and binds all surgical disciplines and proceeds from that commonality. As such, it is unique in its capability to articulate the position of Surgery, with a capital S, in the governmental halls of Advice and Consent.
In our daily practice, as we attend to the needs of one patient at a time, we see the impact of our work on individual lives, and this is a gratifying experience. By becoming active in the American College of Surgeons, each of you has an opportunity to exert your influence on countless numbers of patients and to have input into the development of a health care system that will flourish in this new century. I do not know what the agenda will be for the College in the future, but I do know that you must help to set it. I am confident that you will give that agenda your attention and will set priorities consistent with the mission of the College.
And so, in an historical review of one individual we can find many aspects of surgery as we now know it, and note the many roles that we as surgeons may play: the surgeon as humanist; the surgeon as student and lifelong learner; the surgeon as innovator; the surgeon as educator; the surgeon as scientist; the surgeon as philosopher; the surgeon as role model. These facets of a brilliant surgeon reflect the collegial aspects of his evolution as a surgical leader and remain of vital importance to us today.
Leaders determine the ultimate effectiveness of the organization as their character and skills determine the way in which problems are solved and tasks are accomplished. Never forget that Martin Luther King, Jr., in his profound declaration to the world, said, ‘I have a dream.’ He did not say, ‘I have a very good plan.’ Leaders provide passion and a strong sense of purpose for change. Leaders communicate a vision to their organization and endeavor to build excellence rather than command it.
This century will be a century of change like no other. Successful paradigms of the past and of the present will rapidly fade. Medical education, training, and delivery of health care will radically change, perhaps change akin to that which occurred in the first two decades of the last century.
Delivery of this type of care cannot be done by individuals acting alone; it requires the development of teams, high-performance teams. These teams require leadership. Not the authoritarian leadership of the past, but the kind of leadership that fosters exceptional communication, mutual respect and support, and the development of the best and most straightforward ways to achieve the goals of the mission: improving the health of our patients. Leadership is an area that needs our direct involvement, and the smart surgeon of the future will devote a substantial portion of their time to the study of qualities of effective leaders, to the development of emotional intelligence, and to the improvement of so-called non-technical skills. Your College is deeply involved in these areas and has developed the infrastructure to support it. I encourage you to get involved, not only because it will help your future, but because it is the right thing to do for our patients and our society.
Before you tell me how busy you are, please allow me to visit a discomforting idea on you…and that concept is: Time is infinitely elastic and expands so as to allow you to do the things you want to do. I know this to be true because no matter how busy I find myself, if a truly great opportunity were to arise (say, dinner with Warren Buffett, Ella Fitzgerald, and Walter Cronkite, or a ride on a space launch, for example), I’d simply elbow all commitments aside, and do it. What this actually means, is that when I tell you that I haven’t the time to accede to some request of yours, what I’m actually saying is that I’ve weighed that request on the scale of my priorities and have decided to do something else. Painful but true. I hope you find time to do research.
Part of the stewardship of our profession is our responsibility to one another. When we see our colleagues in need of help, whether it is with regard to acquiring new knowledge or skills or in dealing with personal or professional crises or disabilities, we should help them. Should we see colleagues who have cognitive or physical impairments that do not allow them to continue practice, we must encourage them to modify or change their practice or to step down. If individually we are unable to advise them or influence them, we must ask for assistance from our leaders. Stewardship of our profession does not allow us to look the other way. We all became physicians not only because of our interest in science but also because of our commitment to humanity. Each of us is a steward of our profession by the example we set in our personal and professional behavior. In this time of health care reform, we must be ever-more vigilant in protecting our patients and our profession.
To paraphrase Charles Dickens, this is the best of times, but also the worst of times. Rapid changes in today’s health care environment are leaving some surgeons feeling overwhelmed and isolated. Recent studies report that burnout affects 30 to 50 percent of residents and practicing surgeons, with perhaps surgical residents and women being at greatest risk. While the factors responsible for this situation are not fully understood, increasing administrative and documentation demands, the loss of personal autonomy related to the corporatization of medicine, and long work hours and work-life imbalance are consistently cited as culprits. Added to this are national problems in health care delivery. While lower- and middle-income countries often struggle with a lack of resources and infrastructure, the U.S. has a highly resourced but also highly politicized and dysfunctional health care system with many disparities in the provision of care. It is easy to focus on the daily frustrations of our work environment while losing sight of the great opportunities to improve the care of our patients.
How can we best move forward under these challenging and often frustrating circumstances? As discussed in the August issue of the ACS Bulletin, collaboration with others and participation in efforts that address a common need or common good not only lead to more effective results, but also can be personally rewarding. For those of us who practice oncology, multidisciplinary collaboration is inherent in what we do every day. Increasingly, though, this is true of all surgical specialties. Today, such collaborations may reach across surgical specialties, reach across specialties outside of surgery, or reach across disciplines outside of medicine. As new ACS Fellows, many of you may look to various subspecialty societies as the primary source for education and a forum for scientific presentation in your area of interest.
I emphasize that the College must continue to make a concerted and sincere effort to identify the talented men and women who comprise the Fellowship and can help us confront the multiplicity of problems facing our profession today. These Fellows are already in our midst, and we must find them. With such action, the College emphasizes the role of diversity in its ranks. Furthermore, the time will come, as come it must, when a group of Fellows will be waiting to talk with the President of the College to discuss some business issues. As the Fellows are being ushered into the conference room, the secretary will announce, “The President has just arrived. She will see you now.”
My class, of October 14, 1976, was similar to yours in some ways, but also very different. We were mostly general surgeons who operated with wide exposure; some of today’s specialties did not exist or were in their infancy, such as minimally invasive and endovascular surgery. But the most striking difference between your class and mine is in the number of women: our 15 (1%) to your 307 (22%). The great news about this for leadership at every level of the ACS in the next 100 years is what we know about collective intelligence. The term collective intelligence refers to harnessing the power of a large number of people to solve a difficult problem as a group. And researchers at [the Massachusetts Institute of Technology’s] Center for Collective Intelligence have found that the key factor in success, more important than the individual IQs of the group, more important by far than the IQ of the leader, is a high level of emotional intelligence. In other words, having a successful team, in and out of the operating room, isn’t just about having smart people—it’s about having people who will work together well. And emotional intelligence is strongly correlated with women.
The answers are not clear, but the data speak clearly. Women, as we have seen for the last 20 years, are less likely to rise to leadership roles in their group practices, hospital structures, and professional organizations or through the academic ranks. The ripple effect of this is passed on to our medical students who don’t see women surgeons in leadership roles, but rather as entry-level, stretched young surgeons starting their careers at perhaps the busiest times of their lives, as long-deferred children begin to arrive. But the changing face of surgery is astonishing when we look back over the last three decades. And we can thank our founding mothers for their resilience, remarkable surgical talents, and commitment for the fact that women continue to grow in the surgical ranks, with satisfaction in our careers equal to that of our male colleagues.
In fact, in recognition of our increasingly diverse society, this tenet based on the Golden Rule has been revised to the Platinum Rule, where we, in fact, deal with our patients not only as we would wish to be treated ourselves, but as they wish to be treated based on their own unique ethnicity, gender, background, experiences, culture, and the entirety of their intersectionality. Always remember their valor, their dignity, their humor, and their determination. That is a lot on your shoulders, but you are up to the challenge.
In the midst of the pandemic, we were struck with George Floyd’s death and the disturbing truths it highlighted about racism in our country—drawing attention to an issue so many have tried to hide from or hide in general. The College, which has a long history and strong position on diversity, decided to release a call to action, which it did very quickly. It was a sincere call to action and is one I’m proud of, but the Board of Regents built on this, saying a call to action was just not enough—we need to find ways that we as the ACS are able to improve upon issues of race, the ways we are able to improve surgery and the ways we are able to improve health care.
It’s not enough to be color-blind—we must be color-bold. These conversations are difficult, but we must have them, and they will help us become better surgeons.
On the other hand, much of the fallout from the evolution of the managed care concept has been beneficial to us as surgeons. We have found out that patients can come to the hospital on the morning of the day on which the operation will be performed and survive just fine. We have learned to do operations on an outpatient basis that 20 years ago would have been unthinkable. For the most part, patients like that arrangement better, and in many instances they do better. We have shortened follow-up time with no real loss. If something isn’t working, we still learn about it. We are able to do more cases, and we do them better in all respects. We are forced to look critically at our results and to justify the costs of what we do. When it comes to crisis situations, surgeons, as specialists, are still called upon urgently although not en masse. The “Dr. Pacemaker” call is a thing of the past. Emergency calls are selective with, in most cases, an appropriate response.
The IOM predicted that by 2007 health care in the U.S. will cost more than $2 trillion and require 20 percent of the gross domestic product. Predictably, tension will continue among health care providers, the government, and the corporate world. Although the medical profession has lost power and stature it remains a vital resource enhancing the quality (and quantity) of life. As the health care system for the 21st century evolves, medicine’s role will change, and certainly the way doctors practice the profession will change.
But certain things will remain unchanged. To function effectively in the health care system in the health care industry, we will need guidelines to sustain a focus on the welfare of sick people. To navigate in a trillion-dollar industry, we need a compass: medical ethics. The future medical information system will undoubtedly provide abundant clinical data and the latest in scientific knowledge whenever and wherever we need it. Whether information technology will keep us straight with nonmalfeasance, beneficence, justice, and respect for autonomy remains to be seen.
Ultimately, the responsibility of wisely incorporating new technology into your daily practice lies in the principles you have sworn to uphold as a Fellow of the College and will depend on your integrity, your commitment to lifelong learning, your professionalism, and your desire to put the welfare of your patients above all other considerations.
So much of our orientation today serves to erode our spirit as caregivers. As surgeons, we have experienced and understand the sensitivity and complexity of our relationship with our patients. Too often administrators of our health care delivery systems have neither experienced nor understood that relationship. Our culture as caregivers is being replaced by an overemphasis on process. We are dominated today by a business culture that is eroding our healing relationship with patients. Efficiency and the “bottom line” philosophy must not be ends in and of themselves but means to an end. The moral code that guides our ethics ultimately lies in our own spirituality. Our challenge is to actively participate in the necessary synthesis of these two discordant cultures.
Never forget why you went into medicine in the first place. You can’t always be clever, but you can always be kind. Remember the Fellows Pledge you just recited with John Gage, MD, FACS, ACS Secretary: “…I will place the welfare and rights of my patients above all else. I promise to deal with each patient as I would wish to be dealt with if I was in his position.” There are no unimportant acts of kindness and we, as well as our patients, will be the beneficiaries. Be a joiner. You are now fully fledged Fellows of the College. Follow some of the initiatives in which the ACS is involved, and actively contribute to these activities. Believe me, you can make a significant contribution.
The surgical way of life means that the art and practice of surgery stays in your conscious thought continually. You take “pride of ownership” in patients who have put their trust in your expert hands. You look forward to applying the talents that took you so long to acquire to the betterment of mankind.
The American College of Surgeons could not have picked a better role model for their first President. He was an outstanding clinician, an excellent technical surgeon, and had principles and ethics that the College was trying to promulgate in its efforts to elevate the standards of surgical practice and improve the care of the surgical patient. When he died, his obituary contained statements such as, “idealistic in his attitudes,” “unyielding in his principles,” “selfless,” “inspiring young men and women,” “service to patients,” and “ideal physician.” On his grave stone in Churchville Maryland is engraved “who went around doing good.”
Whether we consider ourselves members of the “House of Surgery” or citizens of the “Village of Surgery” (where there are housing neighborhoods), we have an unbreakable contract with society to provide optimal care for the surgical patient. Such care can be represented as a 3-legged stool, with the 3 legs being quality, safety, and access, respectively. In my opinion, the doors of the “House of Surgery” have always been open to all who need surgical care. However, with a growing population, an aging population (with the associated increase in comorbidities), increasing (and unprecedented) unemployment figures in many areas in America, with declining reimbursement, and innumerable disincentives, the challenges are daunting, for these are the essential ingredients for deepening access problems, which are the underpinnings for health care disparities.
In the end, it is up to each of us to measure, track, and improve our own end results and to achieve our personal best. This should be our message to legislators, insurers, the public, and especially to ourselves. In Dr. Codman’s words, “If not, why not?” If not us, who?
Quality, which will be increasingly data- and outcomes-driven, is the benchmark by which future surgeons will be judged. Surgeons must own quality. Its measurement must be local, personal, accurate, and risk-adjusted. If surgeons don’t become involved in quality improvement and take ownership of this space, someone else will. The ACS has invested millions of dollars in the development of quality programs, but surgeons and their institutions must put them to use to have a meaningful impact on patient care.
Do what’s right for the patient. This proclamation is the bedrock of the American College of Surgeons. It is our lodestar and the cardinal principle of the original Oath of 1913 and of the Fellowship Pledge that Initiates make today. Our calling, our mission, our passion are education and quality. These two objectives have been the watchwords of our College since the beginning. They are today and will be tomorrow. Development and great progress in American surgery have come from surgeons—not imposed from without—who recognized the shortcomings of the present and set out to correct them for the future.