by H. Bryan Neel III, MD PhD
It is a great honor for me to serve as your President this year-the 116th
anniversary of the American Laryngological Association. I am especially
grateful to the members of the Council and Committees for their support
and their many hours of hard work for the Association. We have 12 standing
and ad hoc committees at work on our routine activities and on a large
number of strategic issues, including the formation of a foundation for
adult and pediatric disorders of the larynx under the auspices of the American
Laryngological Association. (The American Laryngological Voice Education
and Research Foundation (ALVER) was organized formally during this meeting.)
Nearly 40% of the entire Active Fellowship participates on one or more
of these committees. We also have a group of representatives to other organizations.
The level of participation and brainpower is truly astonishing.
The Annual Meeting, Scientific Program, and social program are special
occasions for all of us, but it is a uniquely special time for the new
Active, Corresponding, Honorary, and Emeritus Fellows of the Association.
I extend warm congratulations to all of you, your families and friends.
It is a time for celebration. It was a great day in my life in 1981, just
14 years ago, when I was elected to Active Fellowship. I was deeply honored
to become one of the youngest Active Fellows. My proposer was Dr. Al Andrews,
a pioneer in endoscopic laser surgery. We met during a panel on transbronchoscopic
surgery. He spoke about lasers, and my colleague, Dr. David Sanderson,
and I spoke about cryosurgery of tracheobronchial structures and introduced
a long probe and probe tips- known as the Sanderson-Neel cryoprobe-for
transbronchoscopic cryosurgery. Incidentally, there is a significant resurgence
of interest in cryosurgery in Europe.
You will not be disappointed, I'm sure, to know that I shall not give
the usual and customary presidential address, for example, on the health
care crisis or the condition of the Association. (It is excellent.) The
nascency of my comments occurred in Lisbon, Portugal, in September 1994
at an international meeting. With some time for reflection, I decided that
I had better prepare something unique, interesting, and optimistic for
you today-perhaps something that would describe some of the marvelous achievements
in our specialty in recent decades.
I had 4 or 5 days of uninterrupted time with a group of internationally
renowned otolaryngologist-head and neck surgeons in the Collegium Oto-Rhino-Laryngologicum
Amicitiae Sacrum; many of them are surgeons, scientists, educators, and
historians. Sitting next to me was our President-Elect, Paul Ward, when
I penned this question, "What are the 10 most significant advances in otolaryngology-head
and neck surgery during the past 40 years?" and asked him to give me an
immediate response. He was preoccupied with the pain from several broken
ribs, so it was a good distraction for him, too. As usual, he was thoughtful
and brilliant. Because I wanted to get a reasonable sample of opinions,
I asked the same question of 21 colleagues at the meeting.
The question was given to faculty members from 11 countries. Eleven of
those polled were from the United States and one each were from Egypt,
Sweden, the Netherlands, Canada, Germany, Israel, Japan, the United Kingdom,
Portugal, and South Africa. Most of the respondents were 55 to 70 years
old. They were faculty members of health sciences centers and all would
be considered scientists, surgeons, and educators, There was a good distribution
among specialties within otolaryngology-head and neck surgery. Twelve were
Association members. Each was given a single sheet of paper and asked to
give spontaneous responses. There was no opportunity for review of books
or other materials, or coaching. Two collaborated with a colleague. Some
added several subgroupings to their major responses. A few gave more than
10 responses. All responses were focused, concise, and returned promptly.
Each individual was assured of confidentiality.
The most common citations were extracted from the responses, then all
of the citations were cataloged into 10 major categories. Citations that
had a strong laryngology orientation were also extracted from the data.
The most common citations in order of frequency were fiberoptics for
diagnosis or treatment 19; operating microscope, microsurgery 13; cochlear
implant 13; stapedectomy 11; lasers and laser surgery 10; skull base surgery
9; tympanoplasty, middle ear reconstruction 9; phonic surgery 7; myocutaneous
flaps 7; microvascular free flaps 7; computed tomography (CT) 7; magnetic
resonance imaging (MRI) 7; evoked responses, auditory brain stem response
4; and conservation laryngeal surgery 4 .
All citations were assembled into major categories, and the most common
citations by category were surgical procedures 66 (stapedectomy 11,
tympanoplasty 9, skull base surgery 9, myocutaneous flaps 7, phonic
surgery 7, conservation
laryngeal surgery 4); optics 45 (endoscopes 13, microsurgery 13,
micro-free flaps 7, FESS 6); electronics, computers 26 (cochlear
implant 13, evoked
response audiometry or auditory brain stem response 4, hearing aids
2); imaging, radiology 20 (CT 7, MRI 7, improved irradiation 3);
biomedical research 17 (molecular biology 7, hearing 3, vestibular 2);
education
12
(much improved training programs 7, greater depth and breadth 4);
lasers 10 (lasers and laser surgery); pharmacology 5 (topical nasal
steroids 2,
antibiotics, etc); instruments, devices 5 (drills, hemovac, miniaturization,
voice prostheses, fine needle aspiration); and new materials 3 (compression
and miniplates 3).
Citations in the 10 major categories with a strong
laryngology orientation follow: surgical procedures (flaps, phonic
surgery, conservation surgery);
optics (endoscopes, microsurgery, free flaps); imaging, radiology
(CT, MRI, improved irradiation); lasers (laser surgery); and instruments,
devices
(hemovac, miniaturization, voice prostheses). Approximately 30%
of all the citations had a strong laryngology orientation, but clearly
there
was
some overlap with head and neck surgery and other disciplines.
I would call to your attention a few other things that were cited only
on one or two occasions: surgery (neurolaryngology and neurophysiologic
monitoring); optics (motion pictures, television monitoring, video documentation,
oximeter); electronics, computers (voice assessment, assessment of risk
factors [staging of cancer]); pharmacology (anesthesia, pain control, histamine2
antagonists, cortisone); instruments, devices (tracheostomy tubes, endotracheal
tubes, catheters, mass spectroscopy, surgical clips); materials (sutures,
especially for microvascular surgery); and prevention and hazardous exposure
(tobacco, acquired immunodeficiency syndrome, and reflux).
Other major but more general advances that I would add would include
the formation of the National Institute on Deafness and Other Communication
Disorders; information exchange (distance learning and telemedicine); mucosal
immunity (secretoryIgA); Epstein-Barr virus as a factor in infectious mononucleosis,
nasopharyngeal carcinoma, and African Burkitt's lymphoma; the great improvements
in the treatment of rhabdomyosarcoma and lymphoma; cryosurgery and cryoimmunology;
photodynamic therapy; and the care of immunocompromised patients (eg, after
transplantation).
Although I cited only some of the major achievements in science and technology
and how they have changed our specialty, I hope that these examples have
convinced you of the value of research and its profound effect on our capacity
to give better care to our patients than was possible less than 40 years
ago. Our patients are no longer the patrons of anatomists, physiologists,
and "cold knife" surgeons. Indeed, they (and we) have become the patrons
of biomedical science, the physical sciences, and technoscience. (1) We
have a rich medical history, and the ongoing triumphs of medical science
are occurring at an astonishingly rapid pace.
In a recent commentary on "The Value of 'Useless' Research," which was
precipitated by a National Science Foundation report urging taxpayer-financed
spending for commercial product-development research, the big picture was
squarely addressed: "Despite current....rhetoric, we do have the highest
standard of living, or close to it, when it's computed properly with purchasing-power
adjusted exchange rates." The writer ventures that "So great, in fact,
is the worth of the best basic research that all modern governments subsidize
its production." He brings into clear focus the inextricable relationship
of teaching and research and why it is remarkable that specialized teaching
institutions can survive: "The answer can only be that combining
teaching and research raises the quality of the teaching by enough to offset
the higher cost of producing it."(2)
Much of the credit should go to our great American universities, public
and private. Certainly, our biomedical research, scientific expertise,
and commitment to compassion have given us the opportunity to improve the
quality of health care, and we must continue to pursue discoveries across
all scientific disciplines. The foundation of this process is in people
and the improved quality of our human resources. In our own small specialty,
wherever one may practice-in a large city, in a rural area, or in an academic
setting-think again about the remarkable improvements that have occurred
in the care of our patients as a result of research (controlled observations,
reflection, and experimentation), standardized education programs, and
the certification process!
Yes, there are threats to our progress. What are they? I submit the following
in no special order as worthy of your thought, time, and involvement. First,
the antivivisection movement. It is growing in strength and momentum and
is supported by large sums of money and misdirected individuals. Second,
the reorganization of medicine. No new public or private programs have
made provisions for the cost of education and research. Cuts in state and
federal expenditures for higher education, especially for our major land
grant universities, which were established to integrate education and research
and quite simply, to solve problems. Consider their extraordinary role
in technology transfer and the millions of jobs that follow. Third, the search
for "zero risk." State and federal agencies no longer embrace the concept
of "acceptable risk."(3) We have adopted an overly stringent "one-in-a-million" standard
(eg, a lifetime chance of one in a million of developing cancer from a
given substance). At one point, the Food and Drug Administration adopted
a one-in-a-hundred-million criterion for a growth-promoting drug in cattle.
Later, it resumed to the former threshold in an equally arbitrary fashion.
The regulatory process has become oppressive, and drug and device manufacturing
and testing have been forced offshore to Europe and Asia.
According to the faculty poll, the 10 most significant advances in otolaryngology-head
and neck surgery during the past 40 years are fiberoptics for diagnosis
and treatment; flaps for reconstruction; imaging by CT and MRI; the operating
microscope and microsurgery; the cochlear implant; stapedectomy; lasers
and laser surgery; skull base surgery; tympanoplasty and middle ear reconstruction;
and phonic surgery. Tied for 11th place are auditory brain stem response
audiometry-evoked response audiometry and conservation laryngeal surgery.
When all of the citations from the faculty poll are assembled into major
categories, the 10 most important ones are surgical procedures; optics;
electronics including computers; imaging and radiology; biomedical research;
education; lasers; pharmacology; instruments and devices; and new materials.
Our health and welfare depend on research- basic and applied-and surgeons
should know and understand this better than any other
group of citizens.(4) We can look back with pride on our
accomplishments, but we must engage in the debate to protect the future
and new advances
To quote a prominent Swedish clinician and investigator, "Sophisticated
medical equipment is, perhaps, the best sign that surgery-which began as
a manual and magical art-has matured into an integral aspect of science
and technology."(5)
1. Boorstin DJ. The discoverers: a history of
man's search to know his world and himself. New York, NY: Random House
1983:408-17. Return
2. Miller MH. The value of "useless" research.
Wall Street Journal, September 21, 1992. Return
3. Kelly K. In search of "zero risk." Wall
Street Journal,February 24, 1995. Return
4. Peltier LF, Aust JB, Wangenstem OH. The
education of surgeons. Bull Am Coll Surg 1994;79:8-14. Return
5. Haeger KH. The illustrated history of
surgery. London, England: Harold Stark, 1989:277. top
|
