The 21st annual meeting of the American Association of Endocrine Surgeons (AAES) is our most unique meeting since the founding meeting in Ann Arbor, Mich, in 1980. This year's annual meeting celebrates the new millennium by: (1) conducting a 3½-day meeting (instead of 1½ days); (2) meeting in London, England and Lille, France; and (3) having our AAES Annual Meeting jointly with British Association of Endocrine Surgeons and the Swedish Association of Endocrine Surgeons. Nearly 250 endocrine surgeons from the United States, Europe, and other countries are in attendance at this year's meeting, which has been appropriately entitled, “Millennium Meeting of Endocrine Surgeons.”
One of my passions is the subject of multidisciplinary care, particularly for women with breast cancer. The term interdisciplinary is probably more appropriate. For interdisciplinary implies interdependency. Interdisciplinary care (IDC) links professionals together for a shared process of diagnosis, treatment, and research. Having lived this interdisciplinary experience at many levels, I thought it would be an appropriate subject for my Presidential Address.
Whether the new millennium begins this year or in 2001 is still being debated. What I have noticed since January 1, however, is that people are quite reflective about their circumstances and time is being spent looking at the past, the present, and wondering about the future.
To know where we're going, it is important to understand where we have been. Let me briefly review some of the history of endocrine surgery and the founding of the American Association of Endocrine Surgeons.
Some of the greatest names in the history of surgery have also been prominent endocrine surgeons. These include Kocher, Halsted, Lahey, Crile, and many others. Kocher was the first high-volume endocrine surgeon, and his career provided early evidence of the relationship between a surgeon's experience and clinical outcomes. By the end of his career, he had performed more than 5000 thyroid operations, with a mortality rate of 0.5%.
1That was an incredibly low mortality rate for his era.
- Becker WF
Pioneers in thyroid surgery.
Ann Surg. 1977; 185: 493-504
The American Association of Endocrine Surgeons was founded 20 years ago at a meeting that energized those of us who were there for years to come. Nearly 600 articles have been published to date from the proceedings of the annual meetings of AAES. AAES has certainly fostered the growth of the field of endocrine surgery in the United States and its impact has been felt worldwide. Our meetings have always been lively and they have also stimulated great debates. I think it would be fair to say that many of our current and past AAES members are the modern pioneers of the field of endocrine surgery.
Many of our debates are not completely resolved. We still discuss the extent of thyroidectomy for both benign and malignant diseases. In addition, we debate the adjuvant use of iodine 131, the extent of surgical exploration for primary hyperparathyroidism, and most recently we have been vigorously discussing image-guided parathyroid surgery. Through it all, our debates have been passionate, hard fought, and have resulted in the continued growth and progress of the field of endocrine surgery.
Probably the 2 biggest areas of unfinished business for AAES are fellowship training and national treatment protocols. Our colleagues outside of the United States are ahead of us with their implementation of fellowship training opportunities in the field of endocrine surgery. Two of my recent predecessors as president of AAES, Richard Prinz and Jon van Heerden, have advocated strongly for our proceeding in the United States with the implementation of well thought out and appropriate fellowship training in the field of endocrine surgery.
- Prinz RA
Presidential address: endocrine surgical training—some ABC measures.
Surgery. 1996; 120: 905-912
3In a moment, I will present an update of the operative experience of U.S. general surgery residents with endocrine diseases.
- van Heerden JA
Presidential address: lessons learned.
Surgery. 1997; 122: 979-988
Many years ago a small group of AAES members attempted to convince the National Cancer Institute (NCI) of the merits of organizing and funding a prospective national trial on the treatment of differentiated thyroid carcinoma. Unfortunately, their efforts were unsuccessful. As we will see, there is reason for hope, and we may be able to finish this particular piece of unfinished business.
The performance of safe and effective endocrine surgical operations requires high levels of knowledge and skills. Suitable surgical skills evolve from appropriate training. The operative experience of U.S. general surgery residents with diseases of endocrine organs was studied in the mid 1990s by Claude Organ, Norm Thompson, and myself. We previously published our review of thyroid and parathyroid operative experience in 1995 and the operative experience of adrenal glands, endocrine pancreas, and other less common endocrine organs in 1996.
- Harness JK
- Organ Jr, CH
- Thompson NW
Operative experience of U.S. general surgery residents in thyroid and parathyroid disease.
Surgery. 1995; 118: 1063-1070
- Harness JK
- Organ Jr, CH
- Thompson NW
Operative experience of U.S. general surgery residents with diseases of the adrenal glands, endocrine pancreas, and other less common endocrine organs.
World J Surg. 1996; 20: 885-891
Fig 1 is an update of our previously published reports with an additional 5 years of data.This figure focuses on the total number of thyroidectomies, parathyroidectomies, and adrenalectomies performed by finishing U.S. general surgery chief residents. These most recent numbers are available through the end of the academic year 1998-99. This figure demonstrates a slow but progressive increase in the total numbers of thyroidectomies and parathyroidectomies performed by chief residents. The number of general surgery chief residents in training in the United States has remained relatively constant at around 1000 graduates per year (Table).
Tabled 1Table. Summary of total number of chief residents and general surgery programs
|Total chief residents||995||991||1009||980||1015||1010||996||999||998||1000||1016||991||1021|
Fig 2 examines the same years, but looks instead at the average number of thyroidectomies, parathyroidectomies, and adrenalectomies.The average numbers also moved upward during this time period. The average number of thyroidectomies performed by chief residents finishing their training in 1998-99 was 15.2, the average number of parathyroidectomies was 5.9, and adrenalectomies was 1.3.
The average and total number of operations performed are somewhat misleading as a reflection of overall operative experience of graduates of U.S. general surgery residency programs. Fig 3 demonstrates the maximum number of any one of these 3 procedures that an individual chief resident performed.There were residents finishing training during this study time who had incredibly high numbers of thyroidectomies, parathyroidectomies, and adrenalectomies. Some of these numbers are higher than many general surgeons would experience in a lifetime of performing these operations. While there were residents who had substantially high numbers, there were also residents who had little experience, and in some cases zero experience, with adrenalectomies and parathyroidectomies.
Fig 4 displays the MODE, which stands for the most common number of operations performed.This statistical method corrects for the highly variable experiences between individual residents and displays the most common number of operations performed in each of the 3 categories. The MODE for adrenalectomy was 0 throughout the entire study time. Fig 4 demonstrates that the MODE for parathyroidectomy has recently been 3 while the MODE for thyroidectomies increased somewhat, there has been a recent downturn to 9.
This update continues to emphasize our prior point that there is a highly variable experience among graduates of U.S. general surgery residency training programs with the 3 most commonly performed endocrine operations and that there is a continued need in the United States for the establishment of endocrine surgical training fellowships.
As I conclude this brief review of the past, I am reminded of my first experience with IDC. Dr Bill Beierwaltes, who was the head of the Section of Nuclear Medicine at the University of Michigan and one of the founding fathers of the field of nuclear medicine, used to conduct stimulating and provocative thyroid conferences. In attendance were not only nuclear medicine physicians but also general surgeons like Norm Thompson, Tim Harrison, and others. My first exposure to these conferences was in my senior year of medical school in the late 1960s. I witnessed surgeons and nuclear medicine specialists working collaboratively for the best surgical and nuclear medicine treatment of what were often very complex cases. I was struck at the time that this model of close collaboration was one that ought to be duplicated in other disciplines.
Let me now shift my focus to the present. There is nothing we can do about the past and there may be very little that we can do about the future. The only thing that really counts, is the present.
While there are many factors that impact physicians and surgeons in the United States, I believe that there are 4 major contemporary forces that deserve mention. These are socioeconomic, clinical practice, communications, and organizational forces.
These forces affect our daily practice of surgery. It seems that year in and year out, there are greater restrictions of health care budgets. In the United States, we're being impacted by more managed care. And the term “managed care” is really a misnomer. It should really be “managed money.” The demand for more efficiency and a greater concern for finances have resulted in less emphasis on quality. Given these and other socioeconomic forces, what is needed are more outcomes research and evidence-based medical care. I believe that this is the time for surgeons to take the lead in determining what quality is in our discipline and how best to ensure it.
These issues are complicated and emotionally charged. The field of endocrine surgery is no longer the “sole turf” of general surgeons. Ear, nose, and throat specialists are increasingly performing thyroid and parathyroid operations. Urologists are performing more adrenalectomies, and gastrointestinal surgical specialists are exploring the pancreas more often for endocrine tumors. The use of limited-access surgery is increasing and endocrine surgeons have embraced this approach for adrenalectomies. The role of limited-access surgery in thyroid and parathyroid surgery, as well as pancreatic explorations for endocrine tumors, remains to be proven.
The 1990s have certainly been a time of marked acceleration of emerging technologies. Endocrine and general surgeons may be intimidated by some of these technologies but we, as surgeons, must embrace them. A good example of this is the rapidly expanding use of ultrasound by general surgeons in the evaluation of their patients, as well as in guiding surgical procedures.
The concepts of evidence based medicine and clinical practice guidelines have been around for some time, but these are now being looked at more carefully, particularly in light of the socioeconomic and budgetary pressures on the practice of medicine.
6The critical factor is not to let others develop the evidence based clinical practice guidelines for the field of endocrine surgery. Similarly, clinical trials for the treatment of cancer have also been around for many years but the opportunity is finally upon us to embrace clinical trials in our field of endocrine surgery.
- Barraclough B
The value of surgical practice guidelines.
Aust N Z J Surg. 1998; 68: 6-9
The end of the 20th Century has brought an unprecedented explosion in worldwide communications. The advent of the internet, teleconferencing, and e-mail has dramatically changed the speed and quality of our national and worldwide communications. I am amazed, as I am sure you are, at the number of patients who now come to the office or clinic with information that they have gathered from the internet. Patients are now ready to present us with the “latest and greatest” information they've been able to locate on the internet.
Who could have believed the dominant role that web sites would assume? Fortunately, the leadership of AAES has been focused on the need for a dynamic and creative web site and such a web site exists for our association. But equally as important is the linkage of our web site to other key web sites.
Finally, teleconferencing has been somewhat in its infancy in the 1990s, but recent advances in technology now make teleconferencing more real-time and interactive. Teleconferencing and teleconsulting will assume dominant roles in the new millennium.
Most of us are members of multiple surgical associations and societies. These societies have their agendas and all of them are there for a specific purpose. One of the difficulties that each of us faces is simply balancing our personal and professional needs with those of the associations to which we belong. The American College of Surgeons remains a dominant force in the United States and I'll discuss a new role for the college in a moment. For us, in the field of endocrine surgery, the American Association of Clinical Endocrinologists (AACE) is an association that we need to know more about, possibly join, and participate in their activities.
American College of Surgeons
Historically, the American College of Surgeons has had a major interest in education and socioeconomic issues. More recently, the college has created committees to deal with emerging technologies. The college has always had a strong role in the field of trauma as well as cancer, and it maintains one of the largest cancer databases in the world.
American College of Surgeons Oncology Group
The American College of Surgeons Oncology Group (ACOSOG) was conceived as an idea in 1995, initially funded in 1998, and recently re-funded for an additional 5 years. ACOSOG is one of only 9 NCI cooperative groups in the United States. Its focus is on the surgical management of solid tumors. ACOSOG is the only federally funded surgical trial group in the U.S., and like any organization, it has its structure and table of organization. It is important to note that individual surgeon members are central to the process of protocol development.
We are fortunate that one of our AAES members, Sam Wells, is the group chair for ACOSOG. There are 13 organ site committees, including breast; brain and central nervous system; colon and rectum; eye; gastric; genitourinary; head and neck; hepatobiliary; melanoma; pancreas; sarcoma; thoracic; and endocrine. We are also equally fortunate that one of our AAES members and past president, Orlo Clark, is the chairman of the Endocrine Organ Site Committee. Our past efforts to create a prospective national study on the treatment of thyroid carcinoma failed. We now have a unique opportunity with Drs Wells' and Clark's leadership, as well as other key members of our association, to create prospective treatment protocols for endocrine carcinomas, starting initially with thyroid and adrenal cortical carcinomas. This is an opportunity that all of us should strongly endorse.
American Association of the Clinical Endocrinologists
AACE is a national association whose sole purpose is to further the practice of endocrinology. It is made up of endocrinologists who are predominantly internists, pediatricians and gynecologists with endocrinology interests, and endocrine surgeons. It is an advocate for the highest standards of practice in the arena of medical and surgical endocrinology. A major role of AACE is the promotion of both physician and patient education. This organization has a multitude of activities too numerous to list.
AACE has 3500 members. It also has an outstanding web site, which receives approximately 1,000,000 hits a month from nearly 70,000 users. Fortunately for AAES, there is a hot-link from the AACE web site to our web site. AACE is actively involved in developing clinical practice guidelines in a variety of areas, including the treatment of hyperparathyroidism and thyroid carcinoma. A small subcommittee of AAES is working with AACE to ensure that the surgical aspects of these clinical practice guidelines are appropriately formulated. I hope that the principles of evidenced based medicine are utilized in the development of these practice guidelines. In 1998, AAES had an adjacent meeting with AACE and we are planning another such meeting in 2003 in San Diego.
It is now time to look at the future. It is my passionate belief that IDC and interdisciplinary relationships will be a fundamental component of our collective futures.
As I view the year 2000 and beyond, it would be a reasonable hypothesis to suppose that surgery will retain its central role in many aspects of the management of endocrine diseases. If I follow this hypothesis, it is logical to envision surgeons as the leaders of teams of specialists, including surgeons, endocrinologists, pathologists, radiologists, research scientists, and others. These individuals will have their focus on the diagnosis, treatment, and research of endocrine diseases. The IDC team members will, in turn, maintain important, interactive relationships and communication links with the referring primary care physicians.
Surgeons are natural leaders of interdisciplinary programs. Surgeons routinely interact with teams of health care providers in operating rooms, emergency rooms, and other similar settings. Surgeons, by their very nature, are problem solvers and action-outcome oriented. Surgeons have to focus on all aspects of a patient's diagnosis and treatment, as well as preoperative, intraoperative, and postoperative care and long-term follow-up.
Our AAES colleague, Murray Brennan, published in 1996 his views on the subject of the leadership role of surgeons in cancer care, with an emphasis on soft-tissue sarcomas.
7He stated that surgeons can naturally assume leadership if they: (1) understand the etiology and genetic predisposition (of sarcomas in his article); (2) understand prognostic factors and natural history; (3) perform cost-effective treatment; (4) develop clinical trials; (5) guide advanced disease management; (6) guide compassionate support; and (7) evaluate outcomes.
- Brennan MF
The surgeon as a leader in cancer care: lessons learned from the study of soft tissue sarcoma.
J Am Coll Surg. 1996; 182: 520-529
- Brennan MF
The surgeon as a leader in cancer care: lessons learned from the study of soft tissue sarcoma.
J Am Coll Surg. 1996; 182: 520-529
Center of excellence
Concentrating an IDC team in a specialized center creates a “Center of Excellence” approach to the treatment of endocrine diseases. If the IDC team members are located at the same place at the same time, diagnostic evaluations are better organized, less duplicative, and more efficient. Surgeons can see and evaluate possible operative candidates with medical endocrinologists. Preoperative and post-operative management can be streamlined and expedited. Appropriate consultations with pathologists, radiologists, and others can be obtained during a single patient visit. Fine-needle aspirations, magnetic resident imaging, and other studies can be done during the same visit. Decreasing duplication of diagnostic work-ups, reducing the number of patient visits to specialists, as well as coordinating all aspects of care, can lead to reduced costs of medical care for both patients and society.
Specialists working together invariably leads to high-quality outcomes.
8This same type of IDC can often be accomplished when medical and surgical clinical departments are organized under a combined chairmanship or when an IDC team collaborates at preoperative and postoperative conferences. The bottom line of the IDC team approach is the development of consistent working relationships and mutual respect with peers in other specialty areas.
- Harness JK
- Bartlett RH
- Saran PA
- et al.
Developing a comprehensive breast center.
Am Surg. 1987; 53: 419-423
To date, the “Center of Excellence” approach has been used most widely in the diagnosis and treatment of breast diseases. These centers have demonstrated increased efficiency and increased quality of care.
9They can plan individualized or tailored operations that precisely match the patient's individual clinical situation, lower morbidity rates, and lead the development of innovative approaches to diagnosis and treatment. This model has worked well for breast centers. It can also work as well for “Centers of Excellence” for endocrine diseases.
- August DA
- Carpenter LC
- Harness JK
- et al.
Benefits of a multidisciplinary approach to breast care.
J Surg Oncol. 1993; 53: 161-167
- Chen H
- Zeiger MA
- Gordon TA
- Udelsman R
Parathyroidectomy in Maryland: effects of an endocrine center.
Surgery. 1996; 120: 948-953
Not only should IDC and relationships work at the local and regional level, but they should also work at the national and international levels. We have a unique opportunity to work with the ACOSOG in the development of treatment protocols. Most endocrine tumors are uncommon, and large numbers of surgeons will have to be involved if adequate numbers of patients are to be accrued to these trials. In this regard, it will be important to also open these trials to members of the International Association of Endocrine Surgeons. I want to encourage my colleagues to cooperate with this important effort by ACOSOG.
Another important collaboration for American endocrine surgeons will be working with AACE. AACE is the largest association of clinical endocrinologists in the world. It is in our best interest to jointly develop clinical practice guidelines with AACE and to work with them in other areas of mutual interest. The alliance of medical and surgical endocrinologists is a natural one, and we should be looking for ways to strengthen this relationship.
Before closing, let me take this opportunity to express my special thanks and deep feelings of gratitude to several individuals. First of all, I want to take this opportunity to publicly thank the primary organizers of the Millennium Meeting of Endocrine Surgeons: Jack Monchik (USA); Barney Harrison (UK); Tony Young (UK); Bruno Carnaille (France); and Anders Bergenfelz (Sweden). I also wish to thank the conference organizational staff: Ms Paddy Ellis and Ms Jackie Goldsmith. The dream of this joint meeting began 5 years ago and it is now a reality. We are having a successful meeting, which is the result of hard work by many individuals.
Next, I want to take this opportunity to thank the members of my family who are here for my Presidential Address. I doubt that there is a surgeon in the audience who has not felt that he or she has, on more than one occasion, short-changed the members of their family by being away at work or wherever our surgical journey has taken us. I am proud and pleased that my children (Kelly, Debbi, and Steve), one of my sons-in-law (Chris) and Steve's friend, Laura, are here today. Thank you from the bottom of my heart for making the long journey to London and being with your dad on this special occasion. Perhaps in some small way this experience will help you understand what your father is all about and where he's been when he has not been with you.
Finally, I want to thank Norman Thompson. I first began working with Norm 32 years ago when I started my senior year of medical school at the University of Michigan. Norman was a junior attending at that point and his interest and passion for endocrine diseases was as strong then as it is today. Norman has been my mentor, friend, colleague, and while I never had a brother, he has also been my brother. Norman, I want to thank you for all of your guidance, the wisdom you have bestowed upon me, and the wonderful things that you have done for me. I would not be standing here today if it were not for you. Many thanks!
It has been an honor and privilege to serve as President of AAES this past year and to deliver this address today. I have attempted to focus on our wonderful past, our complicated and exciting present, and what I believe will be the key points of our future. There is no doubt in my mind that the field of endocrine surgery will continue to be a demanding, time consuming exercise involving detailed knowledge of endocrinology, anatomy, and meticulous surgical skills. I believe that the future of endocrine surgery in the 21st Century should be bright provided that we, as endocrine surgeons, maintain our central role in the management of endocrine diseases and also our role as leaders of IDC teams. The future is ours! Let us take it together!
- Pioneers in thyroid surgery.Ann Surg. 1977; 185: 493-504
- Presidential address: endocrine surgical training—some ABC measures.Surgery. 1996; 120: 905-912
- Presidential address: lessons learned.Surgery. 1997; 122: 979-988
- Operative experience of U.S. general surgery residents in thyroid and parathyroid disease.Surgery. 1995; 118: 1063-1070
- Operative experience of U.S. general surgery residents with diseases of the adrenal glands, endocrine pancreas, and other less common endocrine organs.World J Surg. 1996; 20: 885-891
- The value of surgical practice guidelines.Aust N Z J Surg. 1998; 68: 6-9
- The surgeon as a leader in cancer care: lessons learned from the study of soft tissue sarcoma.J Am Coll Surg. 1996; 182: 520-529
- Developing a comprehensive breast center.Am Surg. 1987; 53: 419-423
- Benefits of a multidisciplinary approach to breast care.J Surg Oncol. 1993; 53: 161-167
- Parathyroidectomy in Maryland: effects of an endocrine center.Surgery. 1996; 120: 948-953
*Reprint requests: Jay K. Harness, MD, UC Davis—East Bay, Department of Surgery, 1411 E 31st St, Oakland, CA 94602.
© 2000 Mosby, Inc. Published by Elsevier Inc. All rights reserved.