Presidential Address
The challenges of change: Presidential
Address to the 69th Annual Meeting
of the Central Surgical Association
Madison, Wisconsin, March, 2012
Gerald M. Fried, MD, Montreal, Quebec, Canada
From the Department of Surgery, McGill University Health Centre, McGill University, Montreal, Quebec,
Canada
ACKNOWLEDGEMENTS
FIRST, LET ME start by thanking Dr. Michael Nuss-
baum for that warm introduction. Being elected
President of the Central Surgical is clearly 1 of
the great moments of my professional career. I re-
member my surprise when my name was called
during the business meeting in 2010, and the pride
I felt when Drs. David Mulder and Roger Keith, 2
past presidents from Canada, and such good
friends and mentors of mine, ushered me to the
podium. What an honor it was last year when
Mike Nussbaum passed me the gavel of the Central
Surgical Association. It was particularly meaningful
in the light of his Presidential Address reflecting
on the history of the gavel of the Central Surgical
Association and how it was interwoven with the his-
tory of surgery in North America.1 I feel extraordi-
narily proud to be the 69th President of this
organization and I believe the 5th Canadian to
be elected to this prestigious office. I am humbled
when I review the list of names of my predecessors,
giants in the field of surgery, who have woven the
tapestry of surgical advancement.
This is a photo (Figure) that I showcase promi-
nently in my office, of the 1 occasion when 3 of
the people who had a huge impact on my profes-
sional career development actually came together
Accepted for publication April 27, 2012.
Reprint requests: Gerald M. Fried, MD, Department of Surgery,
1650 Cedar Avenue, Suite D6.136, Montreal, Quebec, Canada
H3G 1A4. E-mail: gerald.fried@mcgill.ca.
Surgery 2012;152:509-16.
0039-6060/$ - see front matter
Ó 2012 Mosby, Inc. All rights reserved.
doi:10.1016/j.surg.2012.04.005
in person in Montreal. Dr. David Mulder, who you
all know well and who is sitting in the audience to-
day, was my initial window on the world of surgery.
In the summer of 1969, I was fortunate to get a
summer job working in his lab, studying pulmonary
dysfunction after hemorrhagic shock. He took me
to see my first operation and has been a friend
and role model to me for >40 years. Dr. Mulder
subsequently became Chair of Surgery at McGill
and hired me to my first and only academic job.
He has had an enormous influence on me, serving
as a guide, a friend, and a shining example to
follow. Dave was the 58th President of the Central.
To the left of Dr. Mulder in this picture is James C.
Thompson, MD. I had the privilege to do a fellow-
ship with him in Galveston, Texas, in one of the
leading gastrointestinal hormone research labs in
the world at the time. He taught me about the
discipline of scientific inquiry, the role of surgeons
in advancing patient care through science, and the
process of running a world-class scientific enter-
prise. I have followed his example in my own
research. Although the emphasis of my research
has evolved over time from GI physiology to educa-
tion and simulation, I have continued to run my
research programs true to his model, and I have
taught each of my students the approach to scien-
tific investigation that Jim instilled in me. Jim passed
away in 2008. I am sorry he could not be here today.
My wife Karen and I spent some time with him
in Galveston shortly before he died. I know that
he would be very proud to see me here today.
Fraser N. Gurd, MD, seen on the far left of
this picture, was the 25th President of the Central
and was Chair of Surgery at McGill and Surgeon-in-
Chief of the Montreal General Hospital from 1962
SURGERY 509
510 Fried
Figure. From left to right: Dr. Fraser N. Gurd, Dr. James C. Thompson, Dr. David S. Mulder, and Dr. Gerald M. Fried
(Montreal, June 20, 1985).
to 1972. He emphasized the importance of the
surgeon scientist. His influence continues to shape
our academic mission at McGill to this day.
To my parents Sam and Pauline, I owe so much
for shaping my life, inspiring me, and instilling in
me the values that have directed me both person-
ally and professionally. My daughter Kimberly, son
Howard and his wife Karen and their daughter
Olivia are true joys in my life. They give me
perspective and balance that are so essential to
my personal and professional success and satisfac-
tion. I am very, very proud of my children.
My wife Karen has been with me every step of
the way. She is my partner in life, an amazing
mother and grandmother, and she lives by a
standard of values that few can match. I want to
thank her publically for all her support and devo-
tion. Without, this I would not have accomplished
even a small percentage of what I have, and I
certainly would not be on the podium today.
I also must thank the members of my department,
especially my minimally invasive surgery (MIS) team
and my assistant Maria Cortese, for their outstand-
ing work and support day in and day out.
THE CHALLENGES OF CHANGE
As Bob Dylan would say, ‘‘the times they are a
changing.’’2 We are living in challenging times.
The economic uncertainty has constrained our
growth and development, and has put us under
great pressure. It will impact the way we are funded
and the resources available for research and educa-
tion. It will demand on us to deliver value in every-
thing we do. That is not an entirely bad thing.
Surgery
October 2012
Political turmoil contributes to uncertainty. The
globalization of the world and the immediacy of
communication mean that political and social
changes occurring thousands of miles away can
impact us directly within a very short period of time.
The way we practice is being threatened. Dis-
ruptive technology has influenced patient choices
and our traditional role in the care of our patients
is being nibbled away by nonsurgical specialists. We
must be conscious that others are offering proce-
dures and interventional care that meet patients’
demands by being less invasive. Although in some
cases they are less effective, our patients have made
the conscious choice to opt for those treatments
because they allow them to return to their normal
lives so much quicker. I urge the young people in
the audience to read Clayton Christenson’s book
The Innovator’s Dilemma.3 We need to keep relevant.
For those who think we are immune to change,
think about General Motors, Kodak, and about
peptic ulcer surgery.
Surgical education needs to deal with the ten-
sion between generalization and subspecialization.
We will have a debate on this topic at our meeting
this year. It is time to stop mourning the work hour
rules and to develop innovative approaches to
preparing the next generation of surgeons for
practice, using the same spirit of creativity that we
have applied to solving clinical problems. We need
to prepare our future surgeons to adopt innova-
tion while in practice and to think outside the box.
We need to adapt to changes in lifestyle and take
advantage of new communication technology to
motivate and share content.
Surgery
Volume 152, Number 4
What is the role of ‘‘general’’ surgical specialty
societies such as the Central Surgical in the era of
increasingly focused surgical practices? How can
we maintain our relevance? Should be redefine
our audience? How can we leverage our breadth of
content to full advantage?
A pessimist sees the difficulty in every opportunity;
an optimist sees the opportunity in every difficulty.
---Sir Winston S. Churchill
Winston Churchill lived in challenging times.
Imagine living for 6 years with bombs dropping on
your heads, with shortages of foods, and with
families torn apart by war. He rose above the times
and helped change the world.
For time and the world do not stand still. Change is
the law of life. And those who look only to the past
or the present are certain to miss the future.
---President John F. Kennedy Address in the
Assembly Hall at Paulskirche in Frankfurt,
June 25, 1963
The time to repair the roof is when the sun is
shining.
---President John F. Kennedy State of the
Union Address to U.S. Congress, January
1962
President John F. Kennedy was an inspiring
orator. He recognized that change is inevitable
and that we need to embrace opportunities to lead
change rather than be reactionary. This is the
moment of opportunity. It is time for us to act. It is
up to us to influence the future of our profession.
We must not continue to be reactive and let others
take the initiatives that will shape our future.
My mentor, James C. Thompson, MD, famously
said ‘‘Without research the surgery of today would
be the surgery of yesterday and the surgery of
tomorrow would be the surgery of today.’’4 We can-
not afford to let the surgery of tomorrow be stag-
nant. As Dr. Jeffrey Ponsky is known to say, ‘‘You
better embrace the future or someone else will eat
your lunch.’’ We run the risk of becoming irrelevant.
Surgeons have always been leaders, and we as a
profession have made huge contributions to pa-
tient care. In his Presidential Address to the
American College of Surgeons in 2000, Dr.
Thompson presented a list of what he considered
to be the 11 greatest contributions to patient care
that evolved from surgical research and innovation
in the latter half of the 20th century.5 Although
each of you may put together a different list,
Fried 511
none can argue about the impact of surgical inge-
nuity on patient care. In the remainder of my talk I
will use MIS as an example of surgical innovation,
because this has been such a central part of my per-
sonal career, and it has provided such valuable les-
sons about introduction of innovation and about
opportunities for improvement in surgical educa-
tion. The lessons learned from the introduction
of MIS into generalized clinical practice are far-
reaching and informative to all in this audience.
SURGICAL INNOVATION
Innovation is the introduction of something
new; a new idea, method, or device and implies
the creation of better or more effective products,
processes, technologies, or ideas that are accepted
by markets, governments, and society. Innovations
represent substantive change and differ from in-
cremental improvements.6
We have not always been successful at introduc-
ing innovation. Despite all our successes, we have
had some miserable failures. Some of these have
been brought to this very society as transformative
innovations, only to melt away under the heat of
scrutiny. We can reflect on the results of gastric
freezing, extracorporeal shock wave lithotripsy for
gallstones, and the Angelchik prosthesis for treat-
ment of gastroesophageal reflux disease. On what
list will natural orifice and single incision laparos-
copy fall?
Not only have we tried to introduce some
innovation and failed, but perhaps even more
painful has been our failure to seize opportunities.
Reflect on the way surgeons ignored flexible
endoscopy and left this to the gastroenterologists.
Now, we are trying hard to bring this back into our
practice. Think of the cardiac surgeons who have
left the development of catheter-based therapies to
the cardiologists as we watch cardiac surgery di-
minish in relevance, Contrast that with the proac-
tive stance the vascular surgeons have adopted to
endovascular ‘‘surgery.’’ I would urge you to read
the book Surgeons and the Scope.7 In his review, Dr.
John G. Hunter said ‘‘James R. Zetka, Jr., describes
how the different approaches toward flexible en-
doscopy and laparoscopy chosen by surgeons fun-
damentally shaped the practice of surgery today.
This information is vital to the understanding of
the marketplace in which surgeons practice.’’
There is a very important lesson in this story.
THE INTRODUCTION OF MINIMALLY
INVASIVE SURGERY
The introduction of laparoscopic surgery into
general surgical practice was made possible by the
512 Fried
intersection of a series of inventions: the develop-
ment of fiberoptics, high intensity light sources to
illuminate the interior of the body, and CCD
cameras to allow the display of the image so that
the entire surgical team could participate in the
procedure. The first ‘‘killer app’’ of laparoscopic
surgery was laparoscopic cholecystectomy. It was
immediately clear that surgeons needed to adopt
this in their practice or risk losing a huge chunk of
business to those who did. How was the practicing
surgeon, already overloaded with clinical respon-
sibilities, going to learn this procedure efficiently
and safely? Many surgeons chose to take weekend
courses, many put on by industry motivated to
expand the market. They listened to some lectures,
watched some videos, and did a lap chole or 2 on
pigs. The lay press castigated us as a profession for
expanding the indications for cholecystectomy and
for exposing patients to unnecessary risks because
we failed to teach ourselves properly and creden-
tial surgeons appropriately.8,9 We were accused of
botching this surgery and the New York Health De-
partment issued guidelines requiring surgeons to
do a minimum of 15 lap choles under supervision
before doing these procedures independently.10
We did not live up to our professional responsibil-
ity. Society calls on us as a profession to manage
ourselves. This is a privilege. We did not rise to
that opportunity, so the health department man-
dated how this procedure should be introduced
in New York state. We had at our disposal a truly ex-
cellent innovation, one that would ultimately trans-
form surgical practice. It is worrisome that it may
have fizzled out because of our failure to introduce
it responsibly, by failing to put our patients first.
We should have developed an educational pro-
gram and criteria for credentialing that protected
our patients appropriately.
The process of innovation goes through phases.
Rogers described a curve to demonstrate the
impact on market share for an innovation as it
progresses from the innovators to early adopters,
to the early majority, the late majority, and finally
the laggards.11 Lead users, a term developed by
Eric von Hippel,12 refers to those who identify
needs in the market place, often before most in
the marketplace even recognize their need. The
lead users stand to personally benefit by devising
a solution to the market needs. This motivation
is helpful, but may clearly bias them in their
evaluation.
Lead users benefit by having a strong sense of
purpose and direction based on their recognition
of the limitations of currently available solutions.
For most of us, the direction to the future is not
Surgery
October 2012
obvious. How do we know which innovation to
latch on to?
Surgeons in practice are exposed to reports of
many different innovations. They are often touted
as ‘‘the next lap chole.’’ How does 1 look at these
putative advances and decide in which to invest the
time and energy required to adopt it into clinical
practice? I have found answering 4 questions
helpful for me to assess new technologies and
procedures.
 Is this addressing a significant clinical need?
 Is it likely to be financially viable?
 What is the added value that this is providing?
 Will the average surgeon be able to adopt this into her
or his clinical practice, or will this only work well in the
hands of few virtuoso technicians?
Let me expand on these issues.
Is this addressing a significant clinical need? We
can identify clinical needs by constantly assessing
our outcomes. By so doing we recognize that there
is a ‘‘cost’’ to surgical care. This is the so-called
trauma of surgery. It is a matter of real importance
to our consumers, the patients, and efforts to
minimize this have led many of the modern
advances. Detailed and thoughtful evaluation of
outcomes, from various perspectives, will provide a
direction to our innovative efforts. Not only must
we think of the patients’ viewpoint, but we must
also consider those of the payers and the end users
(ie, the surgeons).
How will the innovation improve patient out-
comes? Is it more effective in treating the clinical
problem? Will patients be more accepting of sur-
gical treatment? Will the new treatment allow us to
provide more efficient care (more care at less
cost)? Will this innovation result in improved
reliability (ie, less interpersonal variability among
surgeons providing this care)? These are all ques-
tions we should pose as we question how the
innovation will address a clinical problem.
Is this innovation going to be financially viable?
When we evaluate the fiscal realities of introducing
innovation, we must recognize that for the inno-
vation to be successful, it must make sense in the
marketplace. It must be profitable for the manu-
facturer, affordable for the buyer, and withstand
comparison with currently available solutions. Fi-
nally, the user must be reimbursed for its use at a
reasonable level.
Does the innovation bring added value? Prob-
ably the most telling test for an innovation is to
determine its value. Value can be assessed in many
different ways, but if significant added value can-
not be shown, it is unlikely that the innovation will
Surgery
Volume 152, Number 4
gain widespread adoption. Value may be expressed
in financial terms, risk reduction, or some other
measure that would motivate us to trade off some
current resources for the new technology. We need
to recognize that health care spending is not
unlimited. As we look to the future, we will be
under increasing pressure to justify expenses. The
litmus test is whether we would be willing to forego
some resources of equivalent cost to adopt the new
innovation.
We must think a priori about what we hope to
gain and how we will measure the benefit. Will we
reduce complications? Will we make our surgical
procedures more effective? Can we measure im-
proved 5-year survival for cancer, or fewer recur-
rences after hernia repair? Will this enable us to
provide more care for less cost? How do we
evaluate cost? Cost to whom? Will the patients be
more accepting of this than current treatments?
How do we know the patients’ wishes? Could we
have predicted that patients would accept coronary
angioplasty over operative revascularization, even
if they knew that this would be less effective and
associated with higher mortality? What are our
patients willing to trade off? All of these consider-
ations contribute to how we determine the value of
the innovation.
To answer these questions, we are well served to
think of how we will evaluate the innovation. We
must define the metrics and must make the scale
appropriately broad to truly reflect the entire
impact. For example, if we just look at 5-year
survival data, we could not have predicted the
move from surgery to catheter-based treatments
for coronary artery disease.
We need to also consider the potential addi-
tional risk of the innovation, such as death, major
morbidity, cost, or lack of effectiveness. An exam-
ple is the introduction of the laparoscopic ap-
proach to inguinal hernia repair. Although there
are many attractions of this procedure, it also
entails risks not present with the open approach,
such as trocar injuries, bladder injury, vascular
injury, and creation of intra-abdominal adhesions.
Some innovative procedures are successful in
the hands of virtuosos, but the results of the initial
published series cannot be matched as the proce-
dure expands into generalized clinical practice. We
must also consider the learning curve. If it takes
250 cases for a surgeon to be able to perform
laparoscopic hernia repair with the same recur-
rence rate as open repair, is it likely that surgeons
will rush to learn this procedure?13
When we are about to introduce a truly new
procedure, we need to realize that bad outcomes
Fried 513
are possible, even likely to occur, at some unknown
rate, with any treatment. These bad outcomes can
be predicted to occur at random intervals related
to the expected frequency of complications inher-
ent in that technique. Even if the risk may be
proven to be low, a complication during the first
attempt can be devastating. For that reason it is
important to work with the Institutional Review
Board (IRB) to define an appropriate interval to
stop and review the outcomes before passing
judgment on the procedure. The outcomes and
the evaluation intervals are best defined before
starting the clinical evaluation. We must remember
that lead users stand to benefit from being first. It
is good for their practice and good for their career
development. This potential for conflict of interest
must be recognized and managed like we would do
for scientific presentations to our society.
We sometimes look at the IRB as an obstacle to
progress. The IRB can be our partner and ally in
innovation. They help us to really think through all
aspects to ensure that we are not being driven by
personal agendas, that the appropriate resources
are put in place to support the initiative, that
everything is done to minimize patient risk, that
the patient is appropriately informed, and that the
appropriate outcome evaluation is being done.
In an academic institution, the department chair
also has a very important role to play. It is his or her
responsibility to encourage progress. In fact, this is
one of the metrics of performance for the depart-
ment. This needs to be balanced against the expo-
sure to risk from poorly planned introductions of
innovation, and the financial burden that novel
operative care may bring to the institution. It is
useful to put in place a template for the process of
introducing truly novel treatments to ensure an
efficient and transparent methodology based on
some of the points I have brought up today.
Ease of implementation. One aspect of innova-
tion that is often not considered is how to imple-
ment this in a manner that will facilitate wide
adoption. Are very high-level (rare) skills required
for the procedure, device, or therapy to be made
widely available? Even if there is a perceived need
for the procedure, and even if it can be delivered
to the user at a reasonable price point, we need to
determine what is required to educate the user to
implement this safely and effectively.
Successful innovation is usually linked to an
effective educational process. It is important to
ask how we can best protect the patient during the
implementation phase (learning curve), and what
measures we can take to ensure continuous quality
improvement. Our efforts need to be directed to
514 Fried
Table I. Value of simulation in preparation for
introduction of innovative treatments
Defined and predictable instructional material
(curriculum).
Ideal environment for learning (learner centered).
Metrics to measure performance.
Set realistic, consistent, and objective goals
(Proficiency levels).
Can be individualized and scheduled.
Provides objective and specific feedback.
Remediate based on feedback from the OR.
minimize the impact on patients and surgeons
during the ‘‘learning curve.’’ We did not do this
successfully during the introduction of laparo-
scopic cholecystectomy. We should leap at the
opportunity to use innovations that have been
developed in education and training to help us
introduce clinical innovation. In so doing, we con-
sider the educational needs of different pools of
learners. These include the trainees within tradi-
tional resident and fellowship programs, surgeons
in teaching hospitals, and surgeons in community
hospitals. Each of these groups presents a different
reality, and the process of educating and evaluating
them to ensure competence must take into consid-
eration these different contexts, and the availability
of training opportunities afforded to them.
Every surgeon experiences a learning curve (the
relationship between performance and experi-
ence). In surgery, as in any other manual skill
area, different people learn at different rates. The
learning rate may be related to age, motivation,
innate abilities, or experiences in sports and the
arts. For this reason, time or numbers are not
appropriate determinants of appropriate amount
of training.
The role of the whole team should be consid-
ered when developing an educational program for
an innovative procedure. This may not always be
required, but should always be considered. The
early steep phase of the learning curve can be
transferred from the operating room to the simu-
lation lab. In cases where simulation training is
available it can provide notable benefits (Table I).
In the simulation environment, the learner,
rather than the patient, is placed at the center of
the experience. The instructional material can be
defined and predictable (curriculum), and the
learning can be scheduled and standardized. Per-
formance can be measured objectively and stan-
dards of performance can be set so the learner can
work toward a benchmark (proficiency-based train-
ing). Each learner can progress at her or his own
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October 2012
Table II. Development of technical proficiency
Learn properly.
Deliberate practice.
Evaluation.
Feedback.
More practice.
Reevaluate.
This can be enabled by simulation.
Table III. Unique environment for laparoscopic
surgery
Working in a monocular optical environment/limited
depth perception.
Magnification.
Fixed access through trocar/decreased degrees of
freedom.
Fulcrum effect.
Long instruments amplify tremor and provide
dampened tactile feedback.
Critical need for use of nondominant hand.
pace and focus on the specific aspects that she or
he finds challenging. If the metrics can be shown
to be reliable and valid, they can be applied to
verify learning, and used for certification and
credentialing. Unlike the way that lap chole was
introduced with weekend courses after which
everybody received a certificate to put on the wall
and take to the hospital credentials committee, we
can use objective criteria to set a minimum level of
knowledge and performance that should be dem-
onstrated before credentials are awarded. A pro-
cess to develop technical proficiency is outlined in
Table II.
Laparoscopic surgery required skills distinct
from those necessary for open surgery (Table III).
The Society of Gastrointestinal and Endoscopic Sur-
geons developed the Fundamentals of Laparo-
scopic Surgery Program to ensure that every
surgeon could learn and demonstrate proficiency
in these areas in the context of laparoscopic surgery.
This validated program has been shown to be a
highly effective and efficient educational tool. The
skills developed by practice in the simulated
environment can be translated effectively to the op-
erating room,14 and the performance measured in
the simulator was highly predictive of clinical skill
in laparoscopic surgery.15
Building on the general skills required for
laparoscopy, new procedure-specific simulations
have been introduced and shown to be effective
for training and evaluation.16-18 These tools are
Surgery
Volume 152, Number 4
important examples of educational innovations
which we can use to help us to introduce operative
procedures in a safe, responsible, and practical way
to learners at all levels.
After taking a course, there are barriers to
surgeons who want to adopt new procedures in
their home environment. Proctoring, although
very effective, can be logistically and financially
difficult to arrange. It is helpful in any case to
maintain a relationship with the course faculty, to
identify a ‘‘go-to’’ person, and to consult when little
barriers or problems arise early in the phase of
adoption. There is nothing that provides more
useful information to the surgeon adopting a new
technology than to track outcomes. This is the
ideal way to define learning needs.
Credentials. ‘‘Fifty years ago the successful doc-
tor was said to need 3 things: A top hat to give him
Authority, a paunch to give him Dignity, and piles
to give him an Anxious Expression.’’19 The process
of credentialing a surgeon adopting an innovative
therapy into clinical practice is highly variable, be-
cause privileges are an institutional prerogative. At
the least, it should be recommended that the sur-
geon be qualified and competent in management
of the clinical problem to which the new technol-
ogy is being applied, be appropriately trained in
the technology that will be applied to the clinical
problem, familiar with hazards and limitations of
new equipment, and encouraged to develop part-
nerships as needed.
Despite all other considerations that are taken
to help smooth the introduction of innovation,
success also requires an appropriate setting that
includes teamwork (both clinical and technical),
with appropriate equipment and the availability of
human and instrument backup.
Informed consent plays an essential role in
protecting the patient during the introduction of
innovation. Once everything else is in place, the
patient must be appropriately informed, and we
must recognize how much we are invested in this
innovation. The patient deserves a clear descrip-
tion of proven and theoretical benefits, possible
risks, the surgeon’s prior experience, and reason-
able alternatives. It is important to recognize that
patients are highly susceptible to surgeons’
recommendations.
The role for ‘‘general’’ specialty societies in
advancing change. The Central Surgical is a vener-
able organization that was developed to dissemi-
nate new knowledge and to develop personal
communication among the surgeons in the central
region of North America. Many seminal papers
have been read at the Central that have played
Fried 515
a major role in introducing and evaluating inno-
vative surgical treatments. In this era of subspeci-
alization, how can we make regional surgical
societies relevant and attractive to our young
surgeons, and how can we ensure that they send
their best science to our meeting? Can we compete
with a society focused on their subspecialty? It is all
about value. We live in a competitive world. Surgi-
cal specialty societies compete not only with one
another, but also with new and highly effective
communication technologies and an array of
means to disseminate new knowledge with greater
immediacy than can be achieved through once-
yearly assemblies.
We must start by appreciating our strengths:
Like all such meetings, we provide a forum to
disseminate innovation through presentation and
discussion of peer-reviewed new knowledge. We
emphasize the discussion by peers and commit to
allotting more time than most organizations for
discussion. We publish our scientific work and the
discussion in a very highly ranked journal that is
widely distributed within our surgical community.
Our papers have a distinct identification with
our society by being published in a single journal
issue.
As a society that broadly serves the multiple
disciplines of surgery, we have an opportunity to
cross-fertilize. We can take innovations presented
by a colleague working in an area other than that
in which we have specialized and ask, ‘‘How can I
adopt this new knowledge in my area?’’ Our society
provides a much greater opportunity to include
content of broad general interest, such as surgical
education, management of trauma and emergency
surgery problems, and surgical infection, processes
of care, that are relevant to all of our clinical
practices. A broad knowledge base will always
improve our ability to be good doctors. It will
complement our depth of knowledge in a limited
area and will allow us to communicate better with
our colleagues.
In-person meetings like ours help to build
collegial relationships. Our meeting is an ideal
size to intermingle and to get to know one another.
By being somewhat limited geographically, it en-
courages ongoing interaction in between meet-
ings, collaboration in research, mentoring, and
consultation in clinical care. At these meetings, we
are immersed in a learning mode. This differs
from picking up a journal or browsing online for
an hour in the evening. The discussion provides a
context and an understanding that is hard to
capture on the written page, and often flows into
coffee break discussions and lunch conversations.
516 Fried
It is a very efficient means to continuous profes-
sional development.
We at the meeting are obviously the committed
members. We need to spread the word to our
colleagues. The strength of any organization is the
quality of the membership. The members create
the content and the environment. The Central can
be as good as we want to make it. We need to
recognize the value of this society.
In summary, we are in a time of great change.
Let us embrace change and be leaders. We must
constantly reinvent ourselves to be relevant. How-
ever, we need to focus our energies and resources
appropriately. To do this, we must start by under-
standing the goals of change, define the opportu-
nities and risks, and be committed to put our
patients central to these efforts. We cannot suc-
ceed in clinical innovation without paying proper
attention to education, and we must measure the
outcome of our efforts from all perspectives: The
patients, the payers, and the users. Overall, as
professionals we need to govern ourselves and
ensure our respect within the public by being
professional and putting our patients first. We
must remain committed to improving surgical
care through innovation. Although surgery has
made enormous contributions to patient care,
many patients have suffered the consequences as
we ascended the learning curve. A planned and
thoughtful approach to the process of introducing
innovation will serve us all well.
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