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Ann Thorac Surg 2003;75:1685-1692
© 2003 The Society of Thoracic Surgeons
a Johns Hopkins University Medical Institutions, Baltimore, Maryland, USA
* Address reprint requests to Dr Baumgartner, Division of Cardiac Surgery, John Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD21287-4618, USA
e-mail: wbaumgar{at}csurg.jhmi.jhu.edu
Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
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Introduction |
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 Top Introduction Is there an analogy...How do we reinvent...AcknowledgmentsReferences |
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During Dr Alfred Blalock’s speech accepting the Presidency of the American Surgical Association, he said, "It’s a long way to this podium from Culloden, Georgia." For me, it is an even longer way from Fort Thomas, Kentucky. It has been a real honor to serve you and this organization. This past year I have been blessed working with such energetic and dedicated members of our Board and various workforces throughout the organization. Anything that I have achieved is directly due to these individuals.
I would like to especially thank my faculty and residents who have supported me in all my endeavors. I am particularly proud to have them as my colleagues and friends. I have been particularly fortunate to have such wonderful mentors and friends during my career. These include my physician-brother Raymond who provided my initial inspiration to go into medicine; Dr Ward O. Griffin, who as Chairman of Surgery at the University of Kentucky, was a wonderful role model; Dr Norman Shumway, former Chairman of Cardiovascular Surgery at Stanford University a humble, charismatic person who provided the excitement for me for cardiac surgery; Dr Bruce Reitz, my best friend and former Chief of Cardiac Surgery at Johns Hopkins; and Dr Vincent Gott, Chief of Cardiac Surgery at Johns Hopkins, for 17 years who remains a supportive friend and mentor to me. I would like to particularly thank my wife and best friend Betsy and my three children, Bill, Jr., Amy, and Mark for their understanding and support of me over these many years.
Cardiothoracic Surgery will continue to progress in its leadership prominence in patient care, innovation and discovery, and residency education at local and national levels. I hope to reinforce this message to you, that although there are many important issues facing us today, we are a specialty that in fact will transition from being good to being great.
I have been somewhat of a student of Jim Collins, who was a former faculty member at the Stanford University Graduate School of Business and has authored two books investigating why certain companies are considered the best and most enduring among their peer institutions. His recent book entitled, "Good to Great" is an investigation of what characterizes a company that goes from being considered good to being great [1]. A great company demonstrated cumulated stock returns that on average were 7 times greater than the general stock market over a period of several years. Collins contrasts these companies with a comparison group of companies who remained good but did not make the leap to greatness. Several concepts that characterize these good to great companies can be directly attributed to our specialty of Cardiothoracic Surgery.
We are presently confronted with a number of issues that are core to our specialty. I view these issues as opportunities by which we can grow from a good to a great specialty of surgery. I suggest to you that we as a collective group of surgeons as well as our specialty organizations have what it takes to transition our field by capitalizing on these opportunities.
Although major issues such as escalating malpractice premiums, financial debt incurred by our students and residents, and the challenge of resident work hours are deserving of comment, these areas are not specific to our profession. We as thoracic surgeons need to form strong coalitions with other members of the medical profession who as a group need to address these important issues facing all of us in medicine. Particularly in the area of malpractice, we as a Society should align ourselves with the American College of Surgeons. This will be a priority for the STS in the upcoming year. The issues pertinent to our specialty that have received national attention are listed in Table 1.
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Leaders are further characterized as individuals who resolve to do whatever is necessary to make their companies great. It is said that when attributing success, a leader looks out the window and recognizes individuals but when there are failures, the leader looks into the mirror. I believe leaders must also possess strong core values.
When I look at our specialty’s organizations, I am convinced and reassured we have the right people in place to effect the necessary changes needed to take our specialty from good to great. The actions these individuals and their successors take in their leadership roles within their respective organizations are crucial to the future of our specialty. Each of these groups has contributed to the current success of the specialty and will be exceedingly important as we confront our current issues and turn them into opportunities.
Listed in Table 2 are the current and future leaders of our thoracic surgical organizations.
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These individuals who make up all the elements of our specialty, adult and congenital, general thoracic and cardiac, practice and academic all work in an altruistic way for the betterment of our specialty, the enhancement of the care of our patients, and the education of our residents. I believe we do have the right people ready to move towards solving the issues that have been elevated from hallway conversations in our practices to national priorities within our specialty. With this group of committed individuals, we will solve the current areas of concern and take our specialty to a new level of excellence. I will first address the issue of decreasing surgical volume in cardiac surgery.
One of the chapters in the book by Jim Collins is entitled, "Confront the Brutal Facts—Yet Never Lose Faith." Let’s look at some of the brutal facts. What are the facts as we know them today regarding the reduction in cardiac operative volume secondary to decreasing operations for coronary artery disease? These data from the Diagnosis Related Group (DRG) Handbooks compare Medicare [2] volume of coronary artery bypass procedures, valvular operations and other cardiac procedures over the last 5 years (Figure 1). Figure 2 shows comparable data for the Medicare population only. As you can see, in the previous 2 years there has been a 14% decline in the number of procedures being performed for coronary artery disease. There have been a steady increase in the number of valvular operations and a negligible change in other cardiac procedures. An additional significant data element is the aging of our population. Figure 2 forecasts the number of patients age 65 years and older over the next few decades. This dramatic increase is particularly relevant as I address the future operative volume in cardiothoracic surgery.
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Is there an analogy in business? |
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TopIntroductionIs there an analogy...How do we reinvent...AcknowledgmentsReferences |
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As described in the book, Scott Paper, which was the contrasting study company to Kimberly Clark, was faced with the same decision and chose to continue its core business of paper mills. They did not change and 25 years later Kimberly Clark bought Scott Paper.
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How do we reinvent ourselves within the specialty of cardiothoracic surgery? |
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TopIntroductionIs there an analogy...How do we reinvent...AcknowledgmentsReferences |
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At a recent symposium, in part organized by Dr James Cox, management of atrial fibrillation was discussed. There are 3 million people in the United States with atrial fibrillation and the majority of these individuals are on permanent anticoagulant therapy. As you know, Dr Cox developed the Maze operation to effectively treat individuals with atrial fibrillation. Although this operation clearly results in the conversion to sinus rhythm in more than 90% of patients, it is a complex operative procedure, not easily adoptable by other surgeons [5]. In the past year there have been a number of innovative techniques and methods developed to decrease the complexity of the Maze procedure by using various forms of energy to ablate the obligatory nerve pathways involved in the generation of atrial fibrillation. It is estimated that there would be approximately 600,000 people who could be cured with pulmonary vein isolation using various forms of ablative surgical therapy. This is an operation that could also lend itself to a minimally invasive approach using standard thoracoscopic techniques or robotic instrumentation.
We have also seen better treatments for thoracic cancers, successful operations for respiratory failure, and the use of minimally invasive techniques for both diagnosis and treatment of intrathoracic disease. There has been considerable discussion in the literature of minimally invasive techniques. The initiation of robotic devices has the potential of making this a reality that can be scaled across many surgeons. This type of surgery has a significant advantage to our patients, with less pain and morbidity and potentially associated benefits of reduction in length of stay and costs. These devices and their future advancements in technology will require the innovation and expertise of our young pioneers in these areas. One could easily envision a number of surgical procedures being performed in this manner by many individuals in our specialty.
Types of procedures that could be accomplished with robotic technology include atrial fibrillation ablations, placement of epicardial pacemaker leads for biventricular pacing, laser myocardial revascularization, stem cell and gene therapy, as well as current standard operative procedures. These new and old procedures will enhance patient care and continue the surgical excellence that has been so characteristic of this specialty over the last 50 years. All of these new areas in combination with an increased need for our more conventional operations due to an ever increasing aged population will extend and enhance the lives of our patients and continue to provide both personal satisfaction and a vibrant environment for our future surgeons, which will produce a better specialty than we have today.
Do we respond to a decrease in coronary artery bypass procedures like Kimberly Clark reacted to their problem of falling stock by turning it into a major opportunity with the development of newer operative procedures for the betterment of our patients or do we sit idly by like Scott Paper did and await our fate. Our specialty heritage clearly pushes us in the direction of innovation, opportunity, and accomplishment. We are securing this future today by the education and training of bright, energetic, and accomplished young cardiothoracic (CT) surgeons.
In my list of current issues, I’d like to briefly discuss decreased reimbursement as we have observed over the last 10 years. Doctor Tim Gardner in his AATS 2002 Presidential Address spoke eloquently about the history, evolution, and current issues regarding our relationship with government [6]. No one in this specialty has worked harder than Tim in the area of governmental affairs. However, even Tim and his group’s efforts did not have as large an impact as he had hoped. Tim said "Our specialty’s efforts to enlighten members of congress about the threat to specialty care for Medicare patients might have staved off some early, draconian reimbursement reductions, but we have been distinctly unsuccessful to-date in influencing in any substantial way health policy specialists and legislators by our direct political action." The true success of Tim and his group’s efforts, however, was in the area of Cardiothoracic Surgery specialty recognition by our legislators and their legislative assistants. All of us in Cardiothoracic Surgery need to be relentless in the continued education of our legislators regarding future access problems of specialty care by our patients, potentially many of whom are sitting here in this room. We are currently seeing a growing number of internists and family practitioners who no longer accept Medicare patients because of reimbursement issues. I believe we need to quit complaining about our own reimbursement issues—these techniques just have not worked. We need to continue to concentrate on the issue of access for Medicare patients to specialty care. This is a worthwhile goal and one which will eventually gain the attention of our elected officials. It is also a course which will be supported and mandated by the baby boomer generation, who are our future patients.
Similar to the development of innovative operative procedures for the betterment of our patients, I believe surgeons should lead the way in innovations associated with reimbursement. In the area of novel strategies for reimbursement, we don’t have to look deeply in our specialty of thoracic surgery to find one. As we have pioneered new surgical procedures, we also have pioneers in the area of reimbursement.
In March of 2000 the state of Virginia’s cardiothoracic surgeons, cardiologists and hospitals involved in cardiac surgery were organized into a coalition entitled, "Virginia Cardiac Surgery Initiative." Their proposed demonstration project was entitled, "State Wide Quality Focus: Global Pricing for Cardiac Surgery." Led by Dr Jeff Rich, this plan for reimbursement was not based on price or volume of surgical procedures but on quality. This unique reimbursement scheme uses a sophisticated database codeveloped with General Electric Medical Systems to monitor all cardiovascular activity throughout the state. The project has a number of pertinent issues. The global price will consist of all Medicare part A or hospital and part B, which is physician payments by DRG. Each DRG payment, for example, coronary artery bypass grafting, will have a supplemental amount added for outlier care which in effect is a payment to the hospital paid up front for those rare patients who require care beyond the usual length of stay. If physicians work to reduce the number of outliers then the hospital can keep the money thereby providing increased profits. Surgeons benefit because they are able to negotiate their fees with the hospital and through joint agreements can also participate in the increased profits to the hospital. Payers benefit because they have a predictable amount for each patient having cardiac surgery and since it is one payment, their administrative costs are significantly less. Patients benefit because they receive only one bill and most importantly have access to high quality care that is benchmarked across the state. The Virginia cardiac surgery initiative is quality driven and the premise of cost reduction in this project is based on the reduction of complications through data sharing and quality networking among the cardiothoracic surgical groups and their corresponding hospitals. This type of activity clearly shows the ingenuity and innovative character of many members of our specialty and our Society. It also points out the mutual collaboration that can be engendered among cardiac surgeons over a project dealing with surgical outcomes.
Is this the answer to our reimbursement issues? No, not entirely. Only time will tell how successful this initiative is. My point is that this novel scheme was developed by the collaborative and cooperative work of the Virginia cardiothoracic surgeons. Their reaction to falling reimbursement was a positive one leading to the development of a novel approach which could potentially be a win-win situation for providers, payers and most importantly their patients.
Reimbursement is one facet of practice management. The issues of practice management for the young surgeon have usually been learned and adopted by "on the job training." This topic has generally not been considered appropriate for formal educational purposes. Recognizing this need and opportunity to provide leadership in this area, the STS Workforce on Practice Education led by Jimmy Edgerton has developed a program entitled, "Practice Management Issues" which will occur tomorrow afternoon as a concurrent session. The importance of this educational session is punctuated by the presence of Health and Human Services Secretary Tommy Thompson who will speak tomorrow in the leadoff position.
Discussion of my third major issue is somewhat of a paradox in today’s specialty of Cardiothoracic Surgery. On the one hand program directors in thoracic surgery want to increase the number of applicants applying for thoracic surgery residency positions to insure the quality of our future cardiothoracic surgeons. On the other side of this paradox, our graduating residents are somewhat disillusioned and bitter due to a diminished number of desired job opportunities. They want to know from us what we are doing about this problem.
There is no doubt in my mind that we have a current supply/demand issue in our specialty. The 2001 significant downturn in the stock market delayed the retirement of a number of thoracic surgeons. This sudden market change, coupled with declining reimbursement and decreased number of coronary artery bypass procedures, has resulted in a number of academic and private practice surgeons remaining in active practice. This has clearly resulted in fewer available jobs. We need to respond to this current supply/demand issue as well as the continued decrease in candidates wanting to go into our specialty.
During the past year, I’ve had the opportunity to listen to our residents at both national and regional levels. Many feel we haven’t responded appropriately to what they view as a significant problem. A recent job survey conducted by the Thoracic Surgery Residents Association was somewhat sobering both in the quantitative results as well as in the accompanying comments. Their question to us is: Why don’t we decrease the number of slots until this supply/demand crisis is over? Although on the surface this sounds like the correct method, antitrust laws prevent this type of adjustment. Residency Review Committee members can be found guilty of antitrust activities if they agree to limit the number of programs, to limit or increase the number of residents, or to close programs for manpower reasons. The Residency Review Committee makes decisions based upon training and educational issues, the quality of resident education, and/or improvement in a program. It has no role in making decisions to limit manpower for any reason and in fact is prohibited from doing so by antitrust laws.
However, what we can do is to hold our residency programs to the highest standards of training and education. The Thoracic Surgery Residency Review Committee has as its mission to ensure these standards are met by the 94 programs in the country. Having had the opportunity of serving on this Committee for the last few years, I believe the Committee seriously considers this mission. If programs do not consistently meet these standards, they will not be permitted to continue. Since 1999, 5 programs have been placed on probation and 2 residency programs closed.
The ultimate goal of the Thoracic Surgery Residency Review Committee is to raise all programs to the same high bar of educational excellence. If programs are unable to meet that challenge, they will no longer be allowed to participate in the education and training of our residents. As stated earlier I believe we have the leadership and collective experience on our Residency Review Committee (RRC) to make these difficult decisions. This will clearly allow the specialty to maintain great residency programs and eliminate those which don’t measure up to the RRC standard. These actions will have the net effect of reducing the number of residency positions.
My predictions are that there will be an increased need for innovative operations for heart failure, arrhythmias and thoracic cancers and that our increasing aged population will be in need of these and other currently practiced procedures. Combining these two predictions with the recent manpower study [7] reported by Dr Richard Shemin, I would further forcast that the current crisis in the job market will be transient and that in 10 to 12 years we will actually be facing a shortage of cardiothoracic surgeons.
This prediction is reinforced by a recently published paper in Academic Medicine entitled, "There’s a Shortage of Specialists. Is Anyone Listening?" in which Dr Richard A. Cooper, Director of the Health Policy Institute at the Medical College of Wisconsin, outlines his evidence why there will be a future shortage of specialists [8].
I would briefly like to address the supply side of this equation. We have observed a steady and significant decrease in applicants to our specialty. Specifically there has been a 30% decrease in US medical school graduates applying to CT surgery over the last 8 years. We have also observed an overall reduced interest in medical school and specifically surgery as reflected by the steady decline in medical school applications and recently a failure of Surgery Residency Programs to match all of their categorical positions. This decrease in the overall thoracic surgery applicant pool will eventually lead to a decrease in the potential quality of future thoracic surgeons. How should we as a specialty respond? Is there an analogy in the corporate world similar to this issue?
During the 1950s, the great Atlantic and Pacific Tea Company known as A&P and Kroger were both involved in the food retail business [1]. The Atlantic and Pacific Tea Company was a dominant player in the world at that time. It was in the decade of the 60’s that fortune changed for both companies. Kroger transitioned from a good to a great company over the next 25 to 30 years outperforming the overall market by a factor of 10 and 80 times better than A&P. What were the factors that influenced this dramatic change in both companies?
The Atlantic and Pacific Tea Company’s philosophy during the postwar depression era was to provide consumers with inexpensive grocery stores. However, a change occurred in the latter half of the 20th century in which an increasingly affluent society wanted more than food in a grocery store. Americans wanted diversity in their stores. They wanted a deli section, a bakery section, a flower shop, magazines and a pharmacy. In short, they wanted a supermarket where they could easily park and take advantage of what we have learned to call "one-stop" shopping. The Kroger company saw this future trend and changed its entire philosophy from a grocery store to a supermarket. Atlantic and Pacific Tea Company did not and thereby never recovered to the prominence it realized in the 1950s.
How is this related to our continued decrease in applicants for thoracic surgery programs? Early recognition of this trend by the American Board of Thoracic Surgery (ABTS) prompted intense and open discussion of whether our residency program in thoracic surgery should change in response to this early warning sign. We all realized that there are several reasons why our students and residents have decided to pursue careers other than thoracic surgery. The American Board of Thoracic Surgery, however, could only address the residency program in regards to its requirement of obtaining the American Board of Surgery certificate. By making the American Board of Surgery certificate optional, change could then potentially occur in thoracic surgery education.
Nearly four years ago, Dr Fred Crawford as Chairman of the Board started an investigative process which was initiated by a retreat and continued with the solicitation of opinions from all major thoracic surgical organizations, using the Joint Council for Thoracic Surgery Education as the sounding board and coordinating organization. This exhaustive process culminated in the American Board of Thoracic Surgery approving the Joint Council’s eight recommendations with the cornerstone being the removal of the American Board of Surgery (ABS) certification as a mandatory prerequisite to ABTS certification [9].
This single significant action will allow certain programs to develop novel and more pertinent curricula for our thoracic residents under the guidance and standards of the Thoracic Surgery Residency Review Committee and with the assistance of the Thoracic Surgery Directors Association. I believe this action contributed to the initiation of similar curricular discussions within the American Board of Surgery after surgery experienced two consecutive years in which categorical positions in major institutions went unfilled. They are currently evaluating a proposal to create a core surgical experience of 4 years with subsequent specialization in a variety of fields. This would shorten the overall residency program by one year and would still allow residents to quality for ABS certification if they desired. The American Board of Surgery is currently working with vascular surgery and our own Thoracic Board to institute this 4-year core curriculum on a trial basis in selected programs.
We should also consider diversification in our training programs. Vascular surgery has developed pilot fellowship programs combining standard vascular surgical operations with interventional procedures. The results of a two-year integrated fellowship in vascular surgery and interventional radiology were reported by the University of California San Francisco group at the American Surgical Association meeting in April 2002 [10]. Their conclusion was as follows: "Integration of Vascular Surgery and Interventional Radiology Fellowships is possible and is mutually beneficial to both Divisions. Furthermore, the integrated fellowship provides exceptional training for vascular surgery fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing vascular surgeons in endovascular procedures suggested by the Society for Vascular Surgery and the American Association for Vascular Surgery." With the future reorganization of some of our thoracic surgery residency programs, this type of combined program with interventional radiology and cardiology should be piloted in select institutions.
Similar to the successful Kroger Company, the leadership of the thoracic surgery organizations responded by allowing thoracic surgery residency to move in a new direction. Only time will tell whether this will result in a similar success that Kroger realized over the last several decades. I believe, however, this action will result in a significantly better educational experience for our residents. This action further represents a recurrent theme in our specialty of cardiothoracic surgery—providing leadership and innovation—this time in residency education.
I would like to conclude by addressing a changing attitude of some members of our specialty. We need to emphasize the positive aspects of our profession—the real reasons why went into cardiothoracic surgery. We do something unique. We have the ability to improve and save lives, through operations and discoveries from the newborn to the elderly. We should not discourage our students and residents from going into this wonderful and exciting profession. They listen closely to their mentors. After all, this special relationship of mentor to student or resident is why several of us entered the field of Cardiothoracic Surgery. We wonder why residents and students are not going into our specialty. If you were scrubbed with a senior surgeon you respected and was told not to go into Cardiothoracic Surgery, I suspect many of us would not be here today.
Rather than discouraging our students from going into surgical specialties like cardiothoracic surgery, we need to take the time to be more involved in the medical school curriculum at the first year level. In order to increase the number of medical students interested in our specialty, they need to know what we do. All of us have been remiss in not being active participants in our medical schools. Anesthesiology has clearly demonstrated how active participation and engagement by anesthesiologists in medical schools has resulted in increased numbers of students going into anesthesia. In many institutions this does not require considerable commitment of time but rather an interest and a demonstration of our willingness to be involved in such areas as the mediastinal and pleural dissection sessions in anatomy courses, student surgery interest groups, and providing educational experiences both on our clinical services as well as in our research laboratories. This type of engagement with our Hopkins medical students at all levels has clearly increased their awareness of the specialty of Cardiothoracic Surgery.
I have used a number of business analogies to emphasize my points. However, Cardiothoracic Surgery is much more than a business. We are a noble profession dedicated to what is best for our patients, not ourselves. When we discover a new operation or procedure we immediately disseminate it so that all patients can potentially benefit. We don’t conceal it or regard it as a competitive advantage. Our new discoveries and operative techniques are viewed and promoted within a number of wonderful vehicles including our journals, CTSNet, the STS Database and more recently innovative models of performance improvement like the Northern New England Consortium and the many state quality outcome initiatives.
Through CTSNet, the STS has been a driving force for global collaboration in thoracic surgery. The thoracic surgery community has now become a similar driving force across all of medicine through MedBiquitous, a nonprofit consortium that is developing collaborative technologies for medical education. As resident hours decrease and the knowledge base for medicine increases, we need to find new ways of educating physicians that are more time efficient and cost efficient. MedBiquitous is developing a technology blueprint for professional medical education that will embrace a collaborative approach to learning and reinforce physician competence initiatives, providing a timely, relevant educational experience. This represents another innovative and successful educational initiative originally proposed by Dr Robert Replogle during his STS presidency and implemented by Peter Greene.
We should look upon these current issues as opportunities, not unsolvable problems. We all need to become involved in some way. During this past year many of us have engaged our residents in dialog. These individuals represent the future pioneers of our specialty. I borrowed from the American Association for Thoracic Surgery the successful concept of a resident lunch and incorporated it into our STS program for this year. This luncheon was an outgrowth of the practice management initiative and will hope to provide residents with pertinent job and practice information. Resident representatives have been added to virtually all the major thoracic surgery organizations. They provide the necessary opinions from their constituency and represent the future leaders of our specialty. Our residents and young surgeons, however, listen to us as senior members of our specialty. We need to emphasize the many positive aspects of our specialty but at the same time acknowledge the issues and respond in a deliberate and educated manner in addressing their concerns.
Cardiothoracic Surgery will continue to progress in its leadership prominence in patient care, innovations and discovery and residency education at both local and national levels.
Although I probably haven’t convinced some of the skeptics in our specialty, I hope I have demonstrated that there can be positive outcomes in these 5 areas of concern in our specialty through the efforts of dedicated cardiothoracic surgeons—many of whom are in this room. We have a choice—We can lament our current situation or turn it into an opportunity to make this specialty great. Every generation has produced leaders who have strengthened our specialty by enhancing the care of patients, developing new and exciting procedures and operations and acted as mentors to our students and residents. I believe we are clearly experiencing this today with our current generation of young pioneers. We have new operative techniques for the treatment of heart failure, arrhythmias, and respiratory failure, the emergence of robotic technology—new devices for permanent support of patients with endstage heart failure, and newer diagnostic and therapeutic procedures for thoracic and esophageal cancers and consistent and excellent results in congenital heart surgery. Many of you know me as an optimist, but I don’t believe this is naïve optimism. However, there is still considerable work that needs to be accomplished.
To ensure that these advances will continue, our thoracic surgical leadership has to set the stage for the next generation of surgeons. We have the correct leaders in position. We have started the process with renewed attention and enthusiasm to recruitment into our specialty, refinement and change of our residency programs, initial implementation of an innovative reimbursement scheme, a reduction in residency programs which do not meet RRC educational standards, and continued education of our elected officials on the issues directly affecting our patients. Each of us as an individual surgeon makes a difference in the life of a patient every time we go into the operating room. We, cardiothoracic surgeons, clearly have a lot to be proud of. I believe we have set the stage for the transition of this noble profession of Cardiothoracic Surgery from good to great.
I would like to sincerely thank you for the opportunity to serve as your President. I am humbled to be included in the same ranks as the Past-Presidents of this wonderful Society.
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Acknowledgments |
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TopIntroductionIs there an analogy...How do we reinvent...AcknowledgmentsReferences |
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References |
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TopIntroductionIs there an analogy...How do we reinvent...AcknowledgmentsReferences |
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