Presidential address: Art and commitment☆☆☆★★★
Article Outline
Abstract
“...Any man's death diminishes me because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”
—John Donne (1572-1631)
While strolling along the streets of Paris, a prominent philosopher and his companion encountered a magnificent Gothic cathedral with an awe-inspiring forum. Upon surveying the prolific architectural edifice, the companion questioned why these monumental structures were no longer constructed and why they appeared out of vogue. “Commitment” was the succinct reply from the philosopher—“commitment.”
Commitment through college, medical school, internship, residency, and vascular fellowship is a compelling force that affords us the privilege to practice our specialty of vascular surgery. What commitment are we willing to forge in order to secure an enduring specialty that will flourish with the generation to follow? Much is expected of those to whom much is given.
Commitment is encountered in all walks of life. Tomes have been penned regarding commitment in individual lives. Art as a manifestation of commitment has always held a particular fascination for me with its historical perspective, immense related talent, and resultant sensual pleasure. The commitment of the artist and his subjects will be my focus in this address. The painting artist requires talent, well-honed skills, and freedom of expression in order to reveal a visual canvas of enduring quality. Two American artists, Thomas Eakins and Benjamin West, and three of their masterpieces that relate to American medical history (the Thomas Eakins paintings The Gross Clinic and The Agnew Clinic and Benjamin West's Christ Healing the Sick) exemplify commitment.
The crucial task of the artist who would portray the people of any period in history is labored. The English poet and author Thomas Carlyle (1795-1881) put it best: the artist “...could not sing the heroic warrior, unless he himself were at least a heroic warrior too.”1 Eakins was a heroic warrior.
Thomas Eakins's life and work (1844-1916) have held my interest since my early experience at the College of the University of Pennsylvania. His portraits and their subjects' personal contributions to Philadelphia society encompassed the fiber of life in the late nineteenth century United States.
A core curriculum of the classical past and the scientific present based on self-discipline was to govern Eakins' future, as was the egalitarian philosophy of the Philadelphia Central High School. Upon passing the rigorous entrance examination that was required for this institution, Eakins' formal education commenced at 13 years of age. This public school was one of a select few in the United States that had no class distinction for admission. Its graduates were held in high esteem, which provided an entree into the intellectual, scientific, and public life of Philadelphia.1
Eakins maintained a deep interest in anatomy and physiology, which is reflected in his original research presented before the Philadelphia Academy of Sciences entitled, “On the Differential Action of Certain Muscles Passing More than One Joint.” These scientific endeavors led to a series of 1884 experiments photographing moving animals and athletes that became an important contribution to the development of the motion picture camera.
Eakins believed the human figure to be the most important element in painting. The depth of his character portraits, the rigid adherence to the truth, and the energy with which he endowed his painting reflects this belief. His masterpieces have caused many critics to regard him “as perhaps the strongest painter in America.” The choice of subject material is summed up by the artist himself, “If America is to produce greater painters and if young art students wish to assume a place in the history of the art of their country, their first choice should be to peer deeper into the heart of American life....”2 Eakins fulfilled this in his life.
While professor of anatomy at the Pennsylvania Academy of Fine Arts, Eakins returned to Jefferson Medical College to further his knowledge of anatomy. Continued learning was characteristic of Eakins throughout his life, always striving to improve his knowledge and techniques, never closing his mind. Eakins had abandoned the idea of securing a patron or acquiescing to those with societal status to fund his professional career as a portraitist. These two common manners of obtaining financial security were used by prominent contemporaries such as John Singer Sargent and earlier artists such as Gilbert Stuart and Benjamin West. Contrarily, Eakins would seek out his subjects because of their contributions and achievements. Only a quarter of his portraits were commissioned. The professor of surgery at Jefferson Medical College was Samuel Gross, who was one of the most respected surgeons of the era and a magnetic, impressive teacher of strong character whose lectures Eakins attended 2 days a week. Dr. Gross was the perfect subject “hero” to entice to sit for what would become Eakins' masterpiece for future generations, entitled The Gross Clinic.
Eakins' feelings about The Gross Clinic were expressed in a letter to his friend, Earl Shinn: “...far better than anything I have ever done.” In contrast, Dr. Gross's comment after numerous sittings was, “Eakins, I wish you were dead.”3
The Gross Clinic (Fig. 1) is a large (8 ft × 6.5 ft) and ambitious painting of a subject rarely attempted in the modern art of the day and never before executed in the United States.
Fig. 1.
The Gross Clinic by Thomas Eakins, 1875. Courtesy of the Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa.
The profundity of Samuel Gross' (1805-1884) portrait depicted a man of considerable attainment of surgical skill, outstanding clinical acumen, knowledge, and eloquence of teaching. Not only did Gross found, edit, and contribute to numerous medical journals, but he produced several texts that were classics of the time. A prolific writer with a prodigious literary output too exhausting to review, Gross was dubbed the “Dean of American Surgeons.”4
His prodigiousness makes his rise to being the most influential surgeon in the United States and Europe understandable. Many honors were bestowed on Gross, who became the twentieth President of the American Medical Association (1868) and was the founding President of the American Surgical Association (1880). I believe, however, that his greatest ongoing contribution to surgery was to be The Gross Clinic.
The painting depicts an era of surgery (1875) before the acceptance of the Listerian principles of antisepsis. Dr. Gross and his colleagues are attired in drab frock business coats, with their bare hands wielding the scalpel, holding the retractor, passing the instruments (which were kept in a carrying case), and closing the wound. Even the patient retains street clothes and continues to wear socks. Joseph Lister's newly conceived theory of antisepsis (1865) was yet to be accepted by the surgical profession. Lister was a featured speaker in Philadelphia at the International Medical Congress in 1876 and delivered a 3-hour address on the subject5—Dr. Gross was nowhere to be found. Indeed, at the first official meeting of the American Surgical Association, where Dr. Gross was most influential, more speakers opposed Listerian practices than supported them.5
The Philadelphia Centennial Exposition (1875) with its jured art pavilion was the impetus for the production of The Gross Clinic. The spectacular, vibrant visual affect and physical substance of this portraiture of a modern surgical hero was lost on the selection committee. Five of Eakins' portraits were accepted, but The Gross Clinic was rejected due to the blood and the depiction of an actual operation, even though the painting's technical merits and psychologic power were acknowledged. The work was relegated to the U.S. Hospital Building and Army Surgeon General's office, where various medical artifacts were displayed in a mock hospital ward and visitors could have their minor injuries and complaints attended. This was the fate of the greatest American painting at the Exposition—condemned because of the realistic, grisly details of a hero in his surgical surroundings and because of “poor taste” with choice of subject matter.4
The anti-Listerian sentiment yielded to antisepsis, which eventually evolved to aseptic surgical techniques. Fourteen years later, Thomas Eakins was approached by the presidents of the University of Pennsylvania medical classes of 1889, 1890, and 1891 to accept a commission of $750 to paint the portrait of their beloved retiring Professor of Surgery, D. Hayes Agnew. The commission was agreed to by both parties, but when Eakins decided to expand from a conventional single-figure portrait to The Agnew Clinic (Fig. 2), a promise was extracted from the class that members would pose as background figures in his studio.
Fig. 2.
The Agnew Clinic by Thomas Eakins, 1889. Courtesy of the University of Pennsylvania School of Medicine.
D. Hayes Agnew (1818-1892) graduated in 1838 from the University of Pennsylvania School of Medicine. Ten years later, Agnew is found resuscitating the Philadelphia School of Anatomy while maintaining a private surgical practice. With Agnew working incessantly as long as 18 hours a day, the school soon became the most prominent institution of its kind in the city. Agnew was even known on occasion to rob graves in the early morning hours when the supply of corpses became low. Furthermore, he founded a school of operative surgery that required lecturing several evenings a week.2
During the war between the states, Agnew served as an assistant government surgeon and became an expert on the treatment of gunshot wounds. In 1871 Agnew was appointed as the university's professor of surgery. His reputation was held in the highest esteem both in this country and abroad. As a result of this prominence, Agnew was appointed chief consultant in charge of President James A. Garfield when he was shot by Charles J. Guiteau in 1881. This incident subjected him to a great amount of pressure and, possibly, undue criticism.
The writings of Agnew include some 66 papers and six books, the most prominent of which was Treatise on Principles and Practice of Surgery. This three-volume work, revised in 1878, 1881, and 1883, embraced every segment of surgery and was considered the leading surgical text of the day.
The background of The Agnew Clinic, although almost imperceptible at first glance, is far from dormant. Each posing class member's portrait is a worthy piece of art in its own right. The sagas or lives of these students after graduation are interesting and varied.
Emerging from the background of student portraits, we learn of their historic presentation of this masterpiece. In mid-April 1889, the University of Pennsylvania mailed engraved invitations bearing Eakins' likeness of Dr. D. Hayes Agnew's head in the upper corner inviting all recipients to the 115th annual commencement of the Medical Department to be held in the resplendent Academy of Music at noon on Wednesday, May 1, 1889. This was to be no ordinary commencement—Dr. William Osler was to deliver the commencement address before his departure to John Hopkins, and a portrait of the beloved retiring Professor of Surgery, Dr. D. Hayes Agnew, was to be presented to the University. One of the students present at this oration, Howard S. Anders, whose portrait appears in The Agnew Clinic, remarked years later, “It was one of the those milestone occasions and experiences that one forgets only with insanity or death—if one does then.”2
The artist's profound admiration for Agnew was the motive that led him to undertake his largest and most ambitious composition. In preparation for the painting, Eakins visited the clinic many times to observe Agnew operate so he could capture the surgeon's exact expressions.
In contrast to the posing students, Dr. Agnew, serenity himself, would enter the studio and exclaim, “I can give you just one hour,” though he posed approximately 96 hours. Toward the completion of the work, Agnew objected most strenuously to the blood depicted and ordered all blood to be removed, despite the artist's protests for fidelity to nature. Eakins complied. At the unveiling, however, blood was present, although not in the previous quantity or vividness.2
In contrast to Dr. Gross's dark frock coat, Agnew and his associates are clothed in white surgical gowns. This contrast heralded an entirely new concept and era in medicine—antisepsis. The Listerian concepts had recently been adapted by Dr. Agnew. This was due in part to his surgical assistant, J. William White (closing mastectomy incision), who had only lately returned from a year under Lister. Agnew became one of the first surgeons in the United States to pioneer such techniques, to which many surgeons were openly antagonistic. However, Dr. Agnew lent his enormous influence to this concept by his powerful example and teaching. Gradually, antisepsis secured the foothold that it deserved and became the foundation of modern-day aseptic surgical technique.
The operating theater and furnishings were washed with green soap and a 1:40 carbolic solution before their use. The instruments were flamed and basins boiled before being placed in an antiseptic solution (note that the instruments are on a tray in The Agnew Clinic rather than in a carrying case as shown in The Gross Clinic). No gloves were worn, and the surgical mask was not accepted for a number of years to come. The carbolic solution was sprayed at various intervals throughout the operation. A photograph taken of Dr. Agnew's clinic only a year before the production of the painting revealed Agnew with his double chin characteristically explaining the procedure. He was dressed, however, in a buttoned-up frock coat, although a canister of carbolic spray was evident.2
The team around the patient—Dr. White closing the mastectomy incision, Dr. Leidy attentively ready to sponge the wound, Dr. Kirby administering anesthetic by the drop method, and Miss Clymer holding a tray of needed materials—is balanced by Dr. Agnew's forceful portrait despite the asymmetrical arrangement. Far from the geometric center, Agnew's fine head (one of Eakins' strongest characterizations) dominated the whole space, as it stands out in startling relief against a dark background fully illuminated by a strong cold light. Eakins not only applied his outstanding knowledge of drawing, composition, anatomy, and perspective, but also employed his unique constructive ability of modeling in paint. This technique builds up the whole form, giving every plane its proper relation and value so that one has the feeling of being able to encircle the figure.2
More important than technique was the artist's marvelous insight into character. Many prominent Philadelphians vowed never to sit for a portrait by Eakins. One such individual, Edwin Abbey, when asked why replied, “He would bring out all of the traits of my character that I have been trying to hide from the public for years.” There were exceptions though, Walt Whitman being a notable one. He preferred Eakins' portraits to all others because as he said, “I never knew of but one artist, and that's Tom Eakins, who would resist the temptation to see what they ought to be rather than what it is.” All of these truths were best exemplified in Agnew's portrait.2
A student of Eakins, Tommy Eagan, observed an old woman dressed in a bonnet and shawl standing in front of the artist's sketch of Dr. Agnew's head as it hung in the Pennsylvania Academy of Fine Arts. After quite a length of time, Eagan overheard her sigh, “He [Agnew] was a gentleman, and he [Eakins] must be a great painter to be able to paint him that way.” The woman had been a servant in Dr. Agnew's home.2
Although The Agnew Clinic did not arouse such widespread comment and written criticism as The Gross Clinic did, it did create a scandal in the polite art circles of Philadelphia, where Eakins was referred to as a “butcher.” The bloody details of the operating room, and a mastectomy at that, were considered an indelicate subject that offended the eyes of the people of the Victorian City.
Yet not long before his death in 1914, The Agnew Clinic was to bring great satisfaction to Eakins. Dr. Albert C. Barnes, millionaire inventor of the antiseptic solution Argyrol, purchased for his collection of international modern art the sketch of Dr. Agnew that had lain in Eakins' studio for years. This transaction involved a respectable sum of money, which at once became news. The voracious press informed the public that the price paid for the painting might prove to be sensational! The amount was approximately $5000, which was more than three times the commission that Eakins received for any of his other works and almost half of the money he earned from painting during his entire career.2 Thomas Eakins became the dean of American artists overnight. The Agnew Clinic was to be exhibited throughout the country in years to come. Not only did the painting honor the great Dr. Agnew, but it provided the pivotal point for the establishment of Eakins' unparalleled career and reputation.
Tragically, while on a camping trip Eakins drank milk that contained formaldehyde. This common practice of preserving milk soon reached scandalous proportions. The technique was halted but not abolished soon enough. Thomas Eakins was fatally poisoned. The praise and recognition that followed in death were never accorded in life.
A third painting retraces history to 1751 and the founding of America's first hospital, the Pennsylvania Hospital in Philadelphia. Until this event, the infirm in America had no place to reside where care could be rendered for their maladies. The committee that solicited funds for the hospital was chaired by none other than Benjamin Franklin. In 1800, almost 50 years after its founding, the hospital's board of directors resolved to solicit a gift for a newly built wing of the hospital—a painting from the American-born painter, Benjamin West (1738-1820), president of the Royal Academy in London. West was residing in London at the time, where King George III was his principle patron. On granting the hospital's request, the artist submitted specifications for a room for the expressed purpose of exhibiting the painting. This room was immediately constructed6; however, the Pennsylvania Hospital version of Christ Healing the Sick (Fig. 3), did not arrive in Philadelphia until 17 years later.
Fig. 3.
Christ Healing the Sick by Benjamin West, 1817. Courtesy of the Pennsylvania Hospital.
The original version of Christ Healing the Sick was displayed in London with two other of the artist's paintings of similar immense size. This exhibit produced a significant income, which was vital for West because the King had withdrawn his patronage. Furthermore, West's greatest popular public success was derived from the exhibition, with acclaim from all classes of people and the uniformly laudatory press. Although the painting was originally conceived and painted for Pennsylvania Hospital, this version was purchased for the enormous price of 3000 guineas (which was raised from donations) and intended as the founding piece for the British National Gallery. West's stature in his profession was solidified. A second version was painted for the hospital.7
This enormous masterpiece (10 ft × 18 ft) was based on Matthew 21:14-15 (King James version): “And the blind and the lame came to him in the Temple and he healed them...”
Various subjects were derived from cartoons intended for the Chapel at Windsor. These transferred latter-year subjects of West yielded more character, expression, and life, as evidenced by the pale, sickly figure and a concerned family surrounded by anxious onlookers as he is presented to Christ. The usual dissention he encountered in life is depicted by the priests and scribes. Christ's response is one of consolation and compassion to these proffered physical and spiritual afflictions. This transmittal of compassion toward men is overwhelming, as one studies the various individuals. Not only is empathy (“share in another's emotions or feelings”) being exemplified, but also compassion (“sorrow for the sufferings of another or others, accompanied by an urge to help”), a necessary characteristic that patients desire their surgeons to exude.
Without believing in and recognizing commitment, none of these artistic events would have transpired. Commitment developed Eakins' technique, truth, realism, and his egalitarian philosophy, Gross' prodigious documentation and organization of surgery through his writings and leadership, Agnew's development of an operative “team” concept, the application of innovative surgical principles such as Lister's, the leadership of men, and West's transmittal of Christ's compassion toward men.
Commitment to our specialty rests with us. The next generation depends on our current actions. But have we committed to certain identified objectives affecting our future? Views about three areas of concern regarding the future of our specialty were solicited through a questionnaire from the program directors of vascular fellowships. The response to this mailing (89%) was gratifying, as were the in-depth comments or letter accompanying numerous returns. To the responding program directors, I am grateful, and it is this collected data and my amalgamated thoughts that are summarized.
The question “Should vascular surgery be a division of the Department of Surgery or section of General Surgery?” revealed that the majority (68%) presently enjoyed the status of a division. Elevation to a division was desirable according to 88%. Several section heads (4) had a harmonious relationship within their department and were content with that classification. Most all (except one) who led a division believed in retaining that level. Five individuals suggested further representation as a department of vascular surgery, which may well have merit.
Advantages of being a division were control of budget and autonomy. Autonomy afforded more flexibility of policies; of faculty hiring; education of students, residents, and fellows; and growth by controlling all resources. The division status gained economic and organizational independence and provided recognition for vascular surgery as a specific discipline with a separate body of knowledge and goals. These special needs and activities differ from those of general surgery and other divisions. The recognition of division status further allowed a greater representation and parity in departmental affairs and hospital negotiations. This self-determination of priorities was believed to disperse improved control over all aspects of quality patient care.
Forums that discuss the question of combining nonapproved (freestanding) and approved vascular fellowships into a singular fellowship conclude with acrimonious feelings. This creates a greater gulf within our specialty. As pointed out by one respondent, “Any attempt to approve nonaffiliated vascular residency would open the box for approving thousands of internal medicine residencies.” Most of these programs fulfill all other Residency Review Committee (RRC) requirements except for not being associated with an RRC-approved general surgery program. Twenty-six percent of directors of approved programs felt that individuals who graduate from freestanding programs should be eligible for the examination for a certificate of added qualification in general vascular surgery. A committee of program directors has tried to overcome this obstacle. Perhaps it should be revisited. Division within our ranks is of no benefit and is counterproductive.
The RRC's argument regarding affiliation is understandable; however, 65% of the respondents to the survey saw a necessity for enhanced vascular surgery representation on the RRC or creation of a vascular arm of the RRC.
Would a more sympathetic RRC modify various requirements while maintaining exacting standards? Many directors believe that the RRC was primarily interested in protecting the general surgery trainees' experience. The vascular fellowship appeared to be of secondary importance, and there was absence of evidence of a desire to foster the development of vascular surgery. Wheeler8 reported that less than 10% of the American College of Surgeons general surgery initiates performed more than 10 vascular procedures per year, and only 3% of the total case load of the general surgery ABS recertification candidates was comprised of vascular surgery. Yet the RRC continues to require an ever-increasing vascular case load for general surgical trainees, to the detriment of the vascular fellow and our specialty.
Although the activities and actions of the RRC have been thoughtfully reviewed by Robert Barnes,9 I suspect that there may be other methods of resolving this issue. One choice is a coleadership of the freestanding program with an approved program. A second choice is an adoption of the freestanding program by an approved program, maintaining independence but sharing the educational, research, and financial goals of the approved fellowship. Our goal is to produce a quality vascular fellowship graduate, thereby maintaining the quality care of the vascular patient.
The certificate maintained its stature, according to 81% of the respondents. The aforementioned holds true despite the following: the disclaimer regarding the certificate of added qualification in general vascular surgery printed in the brochure for patients “Your Surgeon is Certified by the American Board of Surgery (ABS),” the more recent claim by the ABS that vascular surgery is no more than one of the nine components of general surgery, and a significant reduction in size of the recertification certificate compared to the original issue. If this percentage reduction continues every 10 years, the certificate size will measure 3 inches by 3.7 inches in 2023. The reduction in certificate size will likewise signify a considerable reduction of stature and recognition.
All respondents except one thought that the certificate was necessary. It was suggested that the economics of health maintenance organizations and other health plans would maintain the certificate stature, if it continues to exist. The “general” of general surgery has been deleted by the American College of Surgeons, the ABS, and the RRC. Would consideration of deleting the “general” in the certificate of added qualification in “general” vascular surgery therefore be appropriate? Our society is not named the Southern Association for “General” Vascular Surgery. Vascular surgery is a totally separate and distinct portion of the body of surgery, as are the surgical specialties of cardiothoracic surgery, colorectal surgery, plastic surgery, urology, and others.
Although the certificate has become imperative, control by the ABS is thought by 70% of respondents to be “too much.” Is vascular surgery as a specialty being pushed toward oblivion as suggested by six program directors in the survey? Only 29% were satisfied that the current status is “just right.” John Porter's editorial on the subject in the Journal of Vascular Surgery 10 is recommended for your contemplation. As indicated by the results of this survey, Dr. Porter's ponderings concur with the majority (70%) of fellowship program directors' thoughts.
Although the control exacted by the ABS over the specialty of vascular surgery was viewed as too stringent, 69% of respondents believed that the certificate should remain under the auspices of the ABS. Of this group, 30% expressed the desire to place a time constraint for resolution of current issues. Thirty-one percent desired the creation of an independent board for examination.
Our more recent heritage of board and training program certification is with the ABS and RRC. To gain a better insight into this history and the present thought of these and other controlling bodies, the well-written papers by Paul Friedmann11 and George F. Sheldon12 are brought to your attention. Reluctance to separate from the past should not be a compelling factor to remain under the auspices of the ABS and RRC, if those forces threatening the integrity and existence of vascular surgery become untenable. Horace (65-8 BC) succinctly stated:
“The man who is tenacious of purpose in a rightful cause is not shaken from his firm resolve by the frenzy of his fellow citizens clamoring for what is wrong, or by the tyrant's threatening countenance.”
A contingency plan for considering our own specialty board examination, RRC, and the associated stated concerns is essential if the present dialogue between the program directors and the ABS fails to produce substantive results. Festering of these concerns is only disruptive and injurious. No one denies that ramifications exist that require serious thought and debate, but the fear of these matters cannot cloak a robust specialty. We should not be fearful or apologetic for such activity. As Warren Buffett published in one of his Berkshire-Hathaway annual reports, “Noah did not start building the ark when it was raining.”13 A commitment from the joint council is desired to focus on these areas of contention. A committee should be appointed to examine the issues until their resolution.
Amidst the political wrangling and accusations of “surgical fragmentation” and “franchisement” lies the neglected plight of the patient with vascular disease. The tenet of excellence of patient care for all aspects of their vascular disease is the legacy passed to us by the committee composed of J. E. Wylie, E. J. Thompson, and D. E. Szilagyi that was formed in the early 1980s. This excellence of care was the basis for their pursuit of recognition for the specialty of vascular surgery. It was their belief that our specialty embodied an immense sphere of knowledge only mastered by further clinical experience and education.
To deny the exigency for this vascular specialty in surgery is as much a flaw as was Gross's denial of the Listerian principles. The patient suffered then and will be short-changed now if we subscribe to the thought that the practice of vascular surgery is for all surgical trainees.
Commitment to maintain and enhance our specialty must be an integral part of the vascular surgeon's constituted character. Many before us and amongst us have labored long and hard for the vision of a strong and abiding specialty of vascular surgery. Solvable problems are before us, and we are reliant on your commitment to their solution. Eakins' egalitarianism and fastidious reality recorded a legacy of committed men and women in medicine. West revealed Christ's compassion for man's physical and spiritual afflictions. A commitment of compassion between all of us in surgery is paramount as we strive to resolve these evolving uncertainties to ensure a stalwart and enduring specialty. Finally, the commitment of compassion for our patients in our daily contact is essential, for they are the life blood of any specialty. It is for them that we desire to excel.
Vascular surgeons must prepare for the future to preserve our specialty for quality patient care and the upcoming generation. This specialty was borne in the 1950s and 1960s, experienced adolescence in the 1970s and 1980s, and has now entered adulthood. As mature adults, we must exercise control of our destiny and not allow others to dictate this path. There must be recognition of autonomy through a division or department of vascular surgery. Our certification boards must be sustained. A contingency plan must be developed for board certification and for a program evaluation and endorsement committee as achieved by other surgical specialties. Finally, greater representation on the RRC and the ABS is appropriate for the resolution of the present concerns and longevity of the specialty if it is to remain under the present system.
Only our specialty of vascular surgery can render the latitudinal expertise requisite for the quality care of the patient with vascular disease. With commitment, courage, stout hearts, energy, and resolve of purpose, we face a distinctive moment. Guarding against apathy and complacency and the absorption of our identity, we must define what our robust and noble specialty is and shall be, as we enter this brave new world.
“...never send to know for whom the bell tolls; it tolls for thee.”
References
- . Thomas Eakins—the heroism of modern life. Princeton: Princeton University Press; 1983;
- . The Agnew Clinic. The Medical Affairs Bulletin. University of Pennsylvania. 1969;27:18–20
- . In: Thomas Eakins, Gross Clinic. Vol.2:Cambridge, Mass: Harvard University Press; 1982;p. 123–166
- . The art of healing medicine and science in American art. Birmingham Museum of Art 1981. In: Atlanta: Perry Communications, Inc; 1981;p. 62–79
- . Surgery, an illustrated history. In: St. Louis: Mosby Year Book, Inc; 1993;p. 327–328
- . Morton's history of the Pennsylvania Hospital 1751-1895. In: Philadelphia: Times Printing House; 1895;p. 305–320
- . The paintings of Benjamin West. In: New Haven, Conn: Yale University Press; 1986;p. 142–148
- . Should vascular surgery become an independent specialty? Implications of data about operative experience. J Vasc Surg. 1990;12:619–628
- . The Residency Review Committee for Surgery and the training of vascular surgeons. J Vasc Surg. 1993;17:971–974
- . Editorial. J Vasc Surg. 1993;18:10011
- . Perspectives from the Residency Review Committee. J Vasc Surg. 1990;12:607–610
- . Vascular surgery—a specialty of surgery. J Vasc Surg. 1990;12:611–614
- . The Warren Buffett way. New York: J. Wiley & Sons, Inc; 1994;
☆ J Vasc Surg 1996;24:319-27.
☆☆ From the Mobile Infirmary Medical Center and Department of Surgery, University of South Alabama School of Medicine, Mobile.
★ Reprint requests: S. Timothy String, MD, 171 Louiselle St., Mobile, AL 36607.
★★ 0741-5214/96/$5.00 + 0 24/6/72868
PII: S0741-5214(96)70187-8
© 1996 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. Published by Elsevier Inc. All rights reserved.
