Pro Chancellor, Vice-Chancellor, Distinguished Guests, Ladies and Gentlemen.
On behalf of all those who today have been awarded Dr honoris causa, I sincerely thank Hong Kong University. We are all greatly honoured by such recognition and I, personally, feel unworthy to have been asked to address this unique audience on behalf of my fellow graduates.
One is mindful not only of the long history of the University from the time that it was inaugurated by Sir Frederick Lugard in 1912 but also of the even longer tradition of medical education that there has been in Hong Kong, dating from the establishment by Dr Manson of the College of Medicine. One recognises the distinguished graduates that have contributed to medicine, surgery and wider fields, among the first of whom was Sun Yat-sen.
Although my own University of Edinburgh was not among the original advisors for the establishment of the University, I did have the honour of being a Past President of the oldest surgical institution in the world, the Royal College of Surgeons of Edinburgh, which has since 1950 worked hand in hand with Hong Kong surgeons and administrators to produce what is now a world class centre of surgical excellence.
Nearly all of us present today have been fortunate enough to live through the most remarkable 50 years of medical progress. Indeed, some, may not have been here today were it not for these advances.
Students of my era who were educated in the 1950s saw people die from TB, rheumatic fever and syphilis. Mental hospitals were full of schizophrenics and mental deficiency. We had no powerful antibiotics or immunosuppressive drugs; we had no steroids, or anti cancer drugs, and even anti tuberculous therapy was only just being made available.
Thirty percent of the diseases in modern textbooks existed but had not even been recognised never mind understood, and cancer was a universally fatal disease.
We have lived to see transplantation become an every day event, the heart stopped, operated on and started again, joints from hips to fingers substituted by pieces of metal and GSM systems used to tell skull and brain surgeons where to go and where they are once they have arrived. MRI and CT scans tell us if there is disease, where it is and how far it has extended.
The control of the airway and body chemistry in intensive care units allow surgeons to do all the operations that had been possible and considered in bygone times but which would have attracted a charge of manslaughter had they been performed with such certainty of death.
And so surgeons operated and the operations they did often created the surgeon's persona. In some ways, the bigger the operations the surgeon did the bigger and more important man he was. And I use the male context deliberately because there were few women who took part in this period. We saw of breast cancer operations that involved removal not only of the breast and glands but also of the muscles of the chest wall, limbs amputated not through the bone but disarticulated through the shoulder or hip joints and a gynaecological operation described as a pelvic exenteration a procedure that astonishes present day values.
And it was no wonder that part of co temporaneous thought was that even though God had seen fit to give us a stomach, an appendix, a uterus and knee cartilages, these could be removed if not functioning correctly.
Over the next 30 years surgical attitudes and philosophy gradually changed, but education and training remained much the same. The changes were catalysed by 3 things. Firstly even surgeons realised that some of these old big operations were not something that one human being should inflict on another. Not surprisingly, an increasingly educated and mistrustful public agreed. And thirdly new technology appeared.
None of this technology was invented by surgeons. The outcomes of scanning, screening, transplantation, joint replacement, microsurgery and keyhole surgery were applied by surgeons only too willing to depart from what all realised was an imperfect practice of a craft. These were all made possible from inventions by scientists, pharmacologists and engineers and only applied by surgeons many of whom had to make a sea change not only in technique but in thought. The few left thinking 'big' were considered out of touch dinosaurs. And this makes surgery a much more female friendly environment, which is just as well, because in my University, as in many others round the world, the intake is now 80% female.
And so if this sea change in thought and techniques continues can we ask - what will surgeons be doing in another 25 years? The British Royal Colleges gave diplomas first to naval surgeons whose job it was to amputate gangrenous limbs. They then moved on to give surgical licences to the East India Company doctors, one of whom, William Jardine of Lochmaben Scotland, settled here. Surgery as we know it today has only existed for about 150 years.
The trend now, away from big heroic surgery and the application of pharmaceutical and engineering techniques, makes me wonder if there will be a place for surgeons in the future apart from trauma and transplantation.
The unfolding of the human genome project will make cancer therapy change utterly. I spent my life cutting out cancer. As I said earlier some of my teachers still cut out tuberculous organs an action that is now laughable. But so will my efforts be ridiculed in the future when a carrier is developed that will allow the treatment of cancer by methods not dissimilar to taking a polio vaccine. Instead of taking joints out and substituting pieces of metal, we will inject new cartilage to joint spaces allowing them to regenerate. Already coronary artery bypass surgery is being rendered out of date by the newer generation of stents, and mitral valve surgery, at one time a surgical tour de force, is performed with two tiny incisions. Robotic surgery can now be performed at a distance of a few metres from the patient. It will not be too long before the metres become miles, thus allowing special skills to be available to many.
And I could go on, but this is neither the time nor place for such musings. What we must ask ourselves in planning the future is what the implications for education and more importantly the integration of educative processes will be.
What sort of person should be selected for medical school and as importantly when should they be accepted. Should it be a graduate entry subject as in the USA and if so how do we cope with the 3 year shortfall on manpower. Is it still right to take the 'brightest and the best' from high schools? What will tomorrows public want from their doctor. Should the qualities that directed someone to the church or social work be what we are now looking for to create a holistic contributor to society? Since technology is the driving force of today's medicine and surgery, should doctors not have some knowledge of how to evaluate what the scientists are telling them, in the same way that they must be able to interpret data that their patients now bring to them from the internet. In this litiginous society, how will we introduce new technology to surgery safely.
And finally - dare I say it - will we need medically trained people to do the technical surgery that will exist in tomorrow's world? If there is to be less surgery as we know it today what are the implications not only for training but for the maintenance of competence. And if this is not difficult enough in itself, it all has to be accomplished while maintaining the Governmental responsibilities for the provision of health care to a population.
In other words these are educational and management challenges that will need an integrated approach which is different from what we as surgical educators have been used to in the past. It will require different disciplines to integrate the methodology required for the training of future surgeons who will function in a very different way from my generation.
Sir, again may I thank you on behalf of my fellow graduates for the tremendous honour you have bestowed on us. From a personal point of view, this award augments the pleasure I have had in seeing how surgery in Hong Kong has blossomed in the last 25 years.
When the famous golfer Robert Jones, the founder of Augusta and the Masters tournament, was inducted to the freedom of St Andrews in Scotland he said in his acceptance speech 'You could take everything out of my life other than my times in St Andrews and I would have considered myself very fortunate'. Substitute Hong Kong for St Andrews, and you have sir, my feelings today.
