Presidential address: adjusting the art and the science of surgery.

Why are there so many opinions for surgical treatments? Why do surgeons not agree on the same definitions? To adjust the art and science of surgery, we should understand the reason behind this Tower of Babel and ourselves by grasping the three biological lessons of history. These lessons are instincts of man--our instincts have not changed for as long as there has been recorded history. The lessons were elucidated by Will and Ariel Durant and these are competition, selection, and reproduction. How might they be applied to improving our surgical science? First, competition has always forced individuals or small groups to strengthen themselves with cooperation. Cooperate or not survive. Cooperation increases with social development and technology. Next, we must realize that nature relishes diversity. We are all born unequal and diverse. The second biological lesson is selection; which individual among a diverse group of individuals will succeed (by improving)? Therefore, by nature, man's instincts provide diverse opinions and bias. This creates a myopic view when surgeons try to discern the truth. The results are the trendy bandwagons that divert us, like tonsillectomy. Too much diversity is bad, and a balance is required. Man's third lesson of history is reproduction. Better stated is that nature loves quantity. We naturally give priority to quantity over quality. To obtain quality rather than just quantity, we need the antidotes for competition and diversity--that would be cooperation using the Deming guidelines of leadership, profound knowledge, and technology. One example of this urge for quantity and diversity is our lack of standardized definitions. These three biological lessons can be summarized by viewing competition as an impediment for quality improvement in the complex challenges of modern healthcare. Cooperation (trust) is the antidote to the bandwagon effect of unproven treatments. Cooperation and technology can be joined to establish a successful team using the global technology of the internet ("Club Web"). To improve, we must measure real cases in a registry and generate a standard set of definitions and benchmarks. A focus group that trusts each other through the common interest of a disease or organ could succeed. Only then does comparison (and improvement) become possible.