I wish to examine a serious problem facing American surgery that has plagued us with increasing intensity for years and about which I have some very strong feelings. My remarks will consider the changes occurring in this country in the last 40 years relative to population, technical complexity of medicine, the rise in specialization, and the "marketing" of surgical services for "consumers." I will discuss what has happened in surgical education, certification, and practice during this period and will consider the changes that are needed and the possibility of these changes occurring. This seems, at first glance, to be a subject impossible to encompass in a few pages. However, education, certification, and practice are closely intertwined. I hope that my attempts at simplification and concentration will not fail.
DEMOGRAPHIC CHANGES IN RELATION TO SURGICAL PRACTICE
The changes in demographics in the last 40 years are basically a doubling of the