1998 Annual Meeting Presidential Address

John F. Raycroft, Jr., MD
Atlanta, Georgia
December 4, 1998

If I am going to leave you with anything of value this morning it will not come from science, philosophy or politics, but from a few random observations from 32 years of clinical practice. One or more may strike you as valid.

TRUST:

The first observation is that the public's trust and confidence in doctors, particularly specialists, has never been higher. This, despite or maybe because of managed care; we do have a common enemy. The major factor in this trust however, may be the perception of the now common larger professional groups as families. Patients know that these professionals have come together in mutual respect and that they work and almost live together, and that they share their problems and successes. Public acceptance of large groups is only a little more than a generation old. More and more patients are taking comfort in this atmosphere.

THE TENSION BAND:

The second observation is that tension banding remains a viable and important operative technique. I am using the tension band as a metaphor for all surgical techniques that have been challenged by new procedures. There is a place for each one. Our job becomes harder rather than easier in that we now have to further subdivide the pathology and make the right choices. There is real danger in developing reverence for surgical technique.

A CASE REPORT TO ILLUSTRATE TWO POINTS:

A 21 year old college senior fooling around with her roommates, fell, hit her head and had neck pain. She was not unconscious, no paresthesias or weakness. She drove to an emergency room where an x-ray showed an essentially undisplaced fracture of the anterior/inferior corner of C-5. Fracture line went into the endplate about 1/3rd back. She was air-lifted to a spine center. She had an MRI. No burst fracture, no disc displacement, no cord signal, inconclusive for posterior longitudinal ligament disruption. With no other studies or change on exam, that day she had corpectomy of C-5 with allograft and plating from C-4 to C-6. She did great and came home to Connecticut for follow-up.

First, I think that the fellowship training system as it is currently structured, can place a terribly unfair burden on young men and women as they start practice. The immediate need to be the best and know the most can lead to unwarranted enthusiasm for surgery and extension of indications.

Secondly, with all due deference to Dr. White, I think that instability is frequency hard to evaluate. Immobilization for a while, first-aid if you will, is a concept that can clarify diagnosis. It is not always an acceptable concept in our hurry-up world, but maybe not a bad one.

SMOKING:

Time and time again, patients tell me that the part of the surgical experience that they are happiest about is that they have stopped smoking. This can make you feel both good and bad. I think that insisting on cessation of smoking before elective surgery is the best thing that I do, irrespective of the effect on graft healing.

PHYSICAL EXAM:

There is a story that is favored by surgeons: An orthopedist and a neurosurgeon are riding in a hot air balloon. A storm comes up - wind, rain, fog. The clouds clear and they are lost. They look down to a man in a field - "Hello, Hello, where are we?" "You're in a hot air balloon". "Dam, a neurologist" says the neurosurgeon. "How do you know?" says the orthopedist. "Well, he is absolutely right", says the neurosurgeon, "but it doesn't tell us how to solve the problem."

In no way do I intend to denigrate my neurologist friends. Instead, I want to point out that they are almost always right, the reason being that they always do a physical exam. We not only have to be right, we also have to determine a therapeutic course. Hard to do if you are not right. Again and again, I see patients all set for surgery who have not been examined. History is great, images are great. We need to do a better job of teaching and emphasizing the physical exam.

SERVICE:

Service to your community brings great rewards. There are lots of opportunities and you are ideally suited for it: smart, organized and efficient. It can enrich your life and prevent isolation in the medical community. You do not want all your friends to be doctors.

HAPPINESS:

The happiest people I see in medicine are those who put family first. Not always easy.

EVIDENCE-BASED MEDICINE:

I have lived through multiple attempts to standardize care and now there is another, based primarily on meta-analysis of randomized clinical trials to determine the best available evidence. Not all of you in this room or in our specialties, choose the same treatment for a given diagnosis. Witness our debates. If the process of evidence-based medicine leads to improvement in the quality of our literature and to the development and utilization of sound patient-based outcome instruments, then you will gain valuable information to help you refine your therapeutic choices. In the last decade, commerce has captured medicine. If the process of evidence-based medicine stops or slows at the point of determining treatment algorithms for algorithms sake, then we run the risk of putting powerful tools in the hands of those who seek to criticize us and of stifling innovation and independent thought in the name of quality.

FAME:

"Fame", said Edward Jenner in 1899, when he wrote to a friend about his decision to turn down the offer of the Chair of Medicine at Guy's Hospital. His discovery had controlled the scourge of smallpox and would lead to its eradication. He had it all. "Fame", he said, "is a gilded butt, forever pierced with the arrows of malignancy." A little flowery, but it was 100 years ago. He stayed with his country practice in Gloucestershire and lived out his life doing what he did best.

It is hard for me to know, among so many other gifts, which is the most important that Wayne Southwick gave to me and to his many friends here today. It may have been this: Do what you do best and beware the acquisition of fame. Not a bad recipe for life.

I have enjoyed this year, a delightful cap to my career, and I thank those here who did me the honor. I also thank those who have helped with the journey; family, friends, mentors, partners, and that never-ending wave of student physicians that stimulate us and keep us honest. I have had a great life, personally and professionally, and I wish you the same.

It's time for lunch...







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