It is an honor to hold this position. I am grateful to Asociación Argentina de Cirugía for trusting me for organizing one of the most important surgery congresses worldwide. When you go through the list of surgeons who had this opportunity, those who wrote the history of surgery in our country, it is even more worthwhile: stating with Armando Marotta, on November 17, 1928, and continuing with... Enrique Finochietto, Mario Brea, Juan Michans, Andrés Santas, Wolfgang Lange, Enrique Beveraggi, Vicente Gutiérrez, Frutos Ortiz, those who are with us today in person, and those who have left us, Alejandro Oría, and especially my dear friend and example of life: Leonardo McLean. Thanks to the foreign guests who accepted to come from the most distant places to share their experiences and knowledge, with a humble and generous spirit. You raise the academic level of this event. Thanks to all the national surgeons who chose to be here today to meet face-to-face with colleagues and friends, to give each other again that hug that is so typical of Argentine people and so truly transmits our feelings. Coming to this city living federalism during another somewhat minor event: the Soccer World Cup.

Special thanks to María Inés Boquete, Maine, Ornela Normanno, and Natalia Ingani, a great designer. I am convinced that without them we would not have been able to leave Buenos Aires, not to mention organizing this scientific program. I would also like to offer my appreciation to the Organizing Committee, Dr. Daniel Pirchi, Dr. Pablo Cingolani, Dr. Ignacio Maffassanti, Dr. Emilio Quiñonez, Dr. Lucio Uranga, Dr. Francisco Barragán, Dr. Pablo Medina, Dr. Mauricio Linzey, Dr. Arturo Rodríguez Palermo and Dr. Patricio Mon Fara; to the Director, José Luis Tortosa, and to the Board of Directors. Those who accompany us during these four days will be able to enjoy the most diverse and interesting topics of each specialty, which will be addressed in round tables, symposia, lectures, discussion panels, video sessions and abstract sessions, hands-on courses on laparoscopy, endoscopy and percutaneous surgery; two Official Reports, “Innovations in surgery” and “Video-assisted laparoscopy as first choice in surgical diseases of the gastrointestinal tract”, as well as current and cross-cutting issues raised by the main international guests: innovation, robotic surgery, education, leadership... A symposium has also been scheduled to commemorate the 40th anniversary of the Malvinas Argentinas War.

I would like to congratulate the 146 new members of the Association. Undoubtedly, with you we will continue setting the course of Argentine surgery. I tell you that this decision will make you stand out, and you will find in the Association the tools that will help you develop in your professional career. But at the same time, we are anxiously looking forward to your ideas and initiatives that will favor the necessary changes to continue growing and constituting an institution in which all surgeons in the country feel proudly represented. I want to thank my masters, those who have oriented my life towards surgery as a service to others. They taught me to face the patient, empathize, feel compassion, and acquire manual dexterity, essential in our profession to perform a surgical procedure with competence, safety and ability, always thinking of the benefits for the patient. Firstly, my father Eduardo, a physician rare to find nowadays, a brilliant expert in physical diagnosis, loved by his patients, who explained to me the steps to perform an appendectomy for the first time. He inspired my medical vocation. To Dr. Leon Herszage who, with extraordinary patience, taught us postgraduate-1-year trainees how to operate on our first hernias when we were still unable to grasp a clamp. “Surgery is cutting and tying knots, go practice,” he used to tell us. To Dr. Juan Aníbal Viaggio Senior (and Viaggio Junior as well!), chief of the Department of Surgery of Hospital General de Agudos Dr. Ignacio Pirovano, who taught me the delicate, clean and safe surgical technique: “I will teach you how to prevent loose sutures, the rest is in the books, read them”. To Dr. Eduardo Trigo, Dr. Juan Carlos Olaciregui, Dr. Adolfo Badaloni, Dr. Raúl Ymaz, Dr. Cataldo Acri, Dr. Roberto Bonelli, Dr. Alfredo Bargnia, Dr. Mazzaro Senior., Dr. Ernesto Bavio, Dr. Pablo Sisco, Dr. Baena, Dr. Nora Perrone, Dr. Gerardo Raffo Magnasco, to the entire Department of Surgery of Hospital Pirovano, where I spent some years that influenced my surgical life. A special thanks to my fellow residents at Hospital Pirovano, a group of people with whom I learned to work as a team, share responsibilities and have fun even when we were tired; to Jorge Urbandt, my chief resident, my respects for his career; to Viaggio, Olaciregui, Gianatiempo, Arcos, Dimasi, Laura Linares, my fellow residents, to all of them and to the endless list, my most sincere gratitude because they left an indelible mark on my life as a surgeon.

My memory also goes to those who developed their careers abroad and gave me another perspective of medical practice: Dr. Carlos Pellegrini, an example of an entrepreneur and leader in a society he had to conquer, and Dr. Raúl Rosenthal, a surgeon who taught me to be interested in research. In 1995, I knocked at the door of an office in Universidad Austral, following an idea of my mother, since Dr. Juan Carlos Di Luca and Dr. Marcelo Pellizzari were designing a hospital, the dream of one of the noblest people I have ever met, Dr. Leonardo McLean. That hospital that I love is today a reality, and I have devoted 20 years of my life to it. There I am a surgeon, currently Medical Director, and I have been treated as a patient on many occasions. I joined the Works Committee, in charge of medical equipment. At the University, I started studying Medical Management and joined as a surgeon in 2000, together with Dr. Marcelo Terrés, Dr. De Rosa, Dr. Pedro Saco, and Dr. Ignacio McLean, to start up the Department of Surgery at Hospital Universitario Austral. The motivation to start a hospital in Argentina was incomparable, powerful, and soul crushing. All the energy and concentration were focused on achieving a harmonious and sustained growth, receiving each patient, working in a multidisciplinary way. As the floors were occupied, we opened another one, and turned on the ceiling lights of additional operating rooms. The gradual incorporation of Dr. Pablo Cingolani, Dr. Gustavo Lemme, Dr. Mario Acosta Pimentel, Dr. Guillermo Rosato, Dr. Andres Colombatti consolidated the department. The residency program in surgery started in 2004. And then the fellows joined as junior staff, those engines that, along with the residents, drive us to continue growing. Each resident who completes the program with a fully comprehensive training gives me great satisfaction, as children who leave with the necessary tools to face life. With this wonderful group of people, we learned to provide patient-centered care while keeping fellowship, mutual help, and creating bonds of friendship based on trust and shared experiences. We went through bad times, sometimes with anguish, but always moving forward, with clear foundational ideas.

I have always felt Asociación Argentina de Cirugía as part of my surgical life, a place to work thinking of surgeons nationwide. As a postgraduateyear 3 resident, when I was already President of the Argentine Association of Resident Physicians, Dr. Wolfgang Lange called me to become a member of the Residency Committee; that is how my life began in this legendary institution, where I worked for several years. Once again, Dr. Leonardo McLean invited me to collaborate with his Congress and I got to know another part of the work performed there while dreaming of organizing a congress in the future. Then, I had the honor of leading the College Committee for four years, where I learned a lot about the evaluation of surgery services nationwide, how specialists are certified and re-certified, how to establish standards of care, and organize the Annual Course of Surgery, until the Assembly voted me as President of this Congress. We have chosen “Equity and added value in surgery” as the guiding idea, topics that are currently valid in different professions, but which have special and direct implications in surgery. We live in such a fast paced world that we cannot even think about where we are and just now we have to look ahead to cope with the changes while keeping calm in the midst of a vertiginous life. The traditional leadership tools are not enough. Nowadays people are recruited for their IQ and fired for their deficit in emotional intelligence.

We are buried in information. While this conference is being held, more than 1500 new videos have been uploaded on YouTube, over a million tweets have been posted, and tens of millions of WhatsApp messages have been sent. Over the past 50 years we have moved from the challenge of finding relevant information through a limited and difficult access to the great challenge of selecting relevant information, because the data volume is so large that it becomes very complex to find what we are looking for. To become doctors, we had to incorporate new words, more than 1000 in the first year, reading hundreds of pages of books. But, because the magnitude of the publications we try to learn to stay up to date is such, we would have to enter the school of medicine again every couple of days. Alvin Toffler called the difficulty of dealing with such a fast-paced world “future shock,” which would refer to the shattering stress and disorientation induced in individuals by subjecting them to too much change in too short a time. It is no longer a risk but a real disease. And he wrote it in 1965! In medicine, advances in genomics, precision medicine, the study of the brain and cognitive disorders, the advent of telemedicine, digitization of hospital processes and biotechnology are opening up new unexplored paths, only discovered by those with minds that dare go beyond the limits, investigating, realizing ideas that cannot be carried out without a certain amount of audacity, demanded by the reason of skeptics who only accept tangible and logical evidence. This generates such accelerated scientific advances that health systems cannot incorporate them into their menu of benefits or finance them so that these realities can form part of the physician’s therapeutic toolkit. Physicians are aware of such advances and alternatives and indicate them as new lines of treatment, thus generating claims and lawsuits from patients, who trust their doctors and have full and rapid access to information, demanding the coverage of new therapies or diagnostic methods from public and private insurance companies.

We already know about current developments such as robotic surgery, artificial intelligence applied to medicine, virtual reality, augmented reality, 3D printing, robotic-assisted surgical endoscopy, all tools that favor precision in surgical techniques. No one can be unaware of these advances in our environment. “Any sufficiently advanced technology is indistinguishable from magic.” This quote from Arthur C. Clarke summarizes quite well the future of surgery. The Da Vinci Surgical System has been used for 20 years, and it is expected that many other brands already on the market will continue to spread worldwide. Nowadays we are aware of the benefits of robotic surgery, even though it is used in only 3% of surgical procedures worldwide. In this Congress we will have a robotic surgery course, with international leaders in this field who will explain the benefits for patients and surgeons. These are already facts that we and the members of our surgical teams must know and learn. We do not know what will happen in the future; we will not be replaced by a machine, but we will be replaced by those who have that knowledge. This contrasts with the reality of the access to medicine for the world’s population. Just by looking at a few indicators is sufficient to observe the asymmetries that exist between the inhabitants of a given country, or when comparing different states. We have already studied in the university that living conditions of the society are determining factors for the development and prevalence of diseases. Potable water, sewer systems, precarious housing, poor access to education, lack of urbanization and poor nutrition are some factors that contribute to health problems. Indicators as percent GDP per capita, infant mortality, life expectancy, immunization rate, birth rate and cancer mortality give us a good idea of the priorities of governments.

In the midst of these facts, the COVID-19 pandemic made us realize that our healthcare system is fragile, unbalanced, asymmetrical, unprepared to support a huge number of complex patients at the same time. As Dr. Patricia Turner pointed out today, not even the most accurate prediction could have anticipated this global catastrophe, a real turbulence that killed thousands of people, without giving us time to react properly. Those of us who were able to transform could cope with the pandemic and hold the attention of the general population. It is here that surgeons play a fundamental role in occupying places in the front line of the battlefield, but without holding the scalpel, our best weapon. We had to use our virtues of teamwork but this time changing roles, becoming clinicians, oncall physicians, therapists, kinesiologists. We were an example of resilience, which we trained throughout the professional life, as when we have to reoperate after a complication.

So, we ask ourselves: How can we think about equity in this context? Is it possible to develop technology, to look to the future, without taking care of this present? The word equity comes from the Latin aequĭtas. This term is associated with the values of equity and justice. Equity seeks to promote equality beyond differences in sex, culture, economic status, religion, etc. That is why it is usually related to social justice, since it defends the same conditions and opportunities for all people without distinction, only adapting to particular cases. Equity fights against poverty, discrimination, racism, xenophobia, homophobia, among other issues that foster distance and differences between individuals. When we talk about social equity policies, we are referring to health issues, meaning that health should be accessible to all the inhabitants of a country. With this concept in mind, we must not confuse the goal of the development of new technologies. They help to perform the surgical procedure more precisely, reducing the possibility of error, although they do not always set treatment standards. Without neglecting these technological advances, efforts should be made to ensure that the entire population has access to the health standards defined by the competent health authority, that their needs can be timely met with competent professionals, regular check-ups, adequate diagnoses, emergency care, and effective pharmacological or surgical treatments. It is not a matter of bringing a robot to every hospital in Argentina as a standard in health care. Efforts should be redoubled to move towards integrating the health system to reduce inequalities in access, quality and equity in a cross-cutting fashion and incorporate the public and private health sectors and the social security system. There are wide and unexplained differences in costs and quality between providers and geographic areas. The questions we ask ourselves in terms of our institutional responsibility are: “Is there a lack of surgeons? Is there a lack of qualified, updated, trained surgeons? Or is there a lack of equipment?”.

Another issue to address is the meaning of “adding value to surgery”. This was defined by Michael Portter in 2006 as the “quality at lower cost” equation, for the benefit of patients. Nowadays, the payment model is fee-for-service, regardless of the outcomes. “Physicians are changing about how they treat their patients; they don’t know their patients. In modern medicine they are doing very well, but I don’t know how their patients are doing”, said Dr. Vicente Gutiérrez when he was appointed Illustrious Citizen of the City of Buenos Aires. One can work effectively, but not efficiently, by using more expensive supplies, spending more time in the operating room, or making unnecessary use of hospital beds. To change this model, hospital medical services should have data on the impact the therapies used exert on patients. In our surgical practice we must not only measure the results directly related to the procedure but also consider the physical and psychological disability we cause on patients, how they return to social life and to work. Surgeons play a decisive role in adding value to this cycle, applying appropriate and well-proportioned techniques, at the lowest cost and with good results. There are three factors to consider: surgeons should be qualified, trained, and have adequate competencies. They must be certified by associations respected by their members, made up of experienced professionals, who demonstrate through their experience in health care, teaching and research that they can certify the competencies acquired during the different stages of training and their eligibility in the management of the diseases that fall within the corresponding specialty. For health care providers and hospitals with accredited Surgical Services, with the necessary infrastructure, competent health teams, support areas, complementary services, the quality standards determined by the national authority or international evaluators, evidence-based medicine and patient and family-centered medicine should be mandatory, always justifying the use of new techniques and technology. Funders, whether public or private, who pay for the procedures performed, must first agree on fair fees and appropriate contracts with health care providers before claiming a shift from fee-for-service payment to payfor- performance model. If each party in this equation complies with their obligations, medicine will be more equitable, with added value to medical practice, truly considering the efforts of professional training and of the institutions to keep their personnel trained and their facilities equipped with updated equipment. Organizational charts will move from departments to grouping different specialties focused on problems by disease, making patient management more efficient, favoring multidisciplinary work and teamwork, thus achieving better results. And these results may be published so that patients may be better informed to choose a service or professional.

We said we needed competent professionals. In his speech to the Spanish Society of Surgeons, Dr. Carlos Pellegrini stated: “The intelligent surgeon of the future will dedicate much of his or her time to the study of leadership, the development of emotional intelligence, and the improvement of non-technical skills”. In other words, although technical skills must be acquired, those related to the ability of surgeons to perform specific surgical tasks with the appropriate competence, careful attention and good results, it is also necessary to develop non-technical abilities, which are also learned or developed during the residency programs as several publications have demonstrated. After sharing years of our life in groups of surgeons within a surgical service, one watches and incorporates attitudes of daily practice, especially those related to the direct treatment of patients and relationships with fellow surgeons and colleagues from other specialties: empathy, active listening, compassion, professionalism, teamwork. To experience these attitudes we need human virtues, which are incorporated during a lifetime, good operative habits with different sensitive periods to acquire them more easily at different ages: professionalism, honesty, sincerity, kindness, tidiness, responsibility, solidarity, generosity, magnanimity, humility. These allow us to display attitudes that define the limits of human excellence, to really place the patient at the center of our surgical practice, regardless of the decision we make. Peabody stated: “Patients don’t care how much you know about medicine until they know how much you care about them as persons.” Excellence, innovative spirit, reflectiveness, and inclusion are the differences that exist between a “competent” surgeon and an “excellent” surgeon, which are not synonymous. There are many competent professionals capable of performing perfect surgeries, but few are excellent. Excellence is made up of the ability to transmit confidence and calm under adversity, to empathize, be an active listener, compassionate, share criteria, make good decisions, and have integrity. That combination of art and attitude in a single human being is the gift provided by our profession, which we must understand as a vocation.

Vocation is the tendency that a person feels to dedicate himself or herself to a way of life, either professionally or spiritually. The term comes from the Latin “vocatio” which means “calling”. We all have a vocation that we must discover to be happy and do our daily work with passion, satisfaction, finding a meaning to our life. But nowadays vocation is in crisis. Vocation is not easy to find due to a lack of vision and ability to live. People seldom ask themselves about the meaning of life. The greatest increase in the attrition rate and the decline in the number of candidates for residency programs in the different provinces occurs in surgery. There are many difficulties in the country to financially support the residency programs, as it happened during the last 12-day strike to obtain a decent salary. In times of William Halsted at the Mayo Clinic, residents spent an unlimited amount of time at hospital with the goal of receiving supervised training. Nowadays, although it is the only training tool, it is considered as just another job by many young people, with all its laws. It takes many years before being able to start practicing as a specialist, not to mention the time involved in subspecialization. And on this long road, the probability of losing this vocation increases as we find satisfaction of our transcendent needs in other shorter roads and our personal wishes are immediately satisfied. It is our responsibility to illustrate by our example that this is a hard, long and difficult road, but that it gives us a unique opportunity to be happy seeing the fruits of our well-done labor. I asked a question to 20 physicians, most of them surgeons who had marked my life: “After so long in the profession, what gives you peace and joy?”. Most of them answered: my family, my children, my grandchildren (“I took time away from my family, I spent little time with them”), and trust in God. Some said: “surgery”. Certainly, our anchor, what makes us strong in the face of adversity, what supports us, is what at the end of the day suffers the most as we try to find the balance between work and family. The reconciliation of family and work is a pending debt we have in our profession.

We list many virtues and attitudes that we must develop to be surgeons of excellence, all of which ultimately have an impact on patient-doctor relationship. But time is the most limiting issue to live them. In medical practice, the adjustment variable to make the profession profitable is to see more patients, to operate on more patients in less time, leaving aside that valuable moment of receiving a patient, looking him or her in the eyes, listening to his/her complaints, fears and uncertainty with empathy and compassion, getting to know him or her. The sublime moment in which we generate trust, when the patient is fully surrendered to our hands. That time to look at an exam, discuss it, make multidisciplinary decisions on the indication for surgery, and define the surgical strategy as a team. And in the postoperative period: talking to the family, the doctors who are going to receive the patient, the nurses who are going to take care of them, closely following their progress. Nothing and no one should make us lose those moments. This is the main value of our time, and it will not be replaced by any technology of the robotic era or artificial intelligence; we have the privilege to serve our fellow man by doing what we love and learned to do best, using not only our hands but also our hearts. This also gives us happiness. Do not let any external interest come between the patient, who surrenders with full confidence, and us, the surgeons, at that moment.

In summary, I go back to the beginning and simply dedicate a few words of gratitude, especially to God, who has never let go of my hand at any moment of my life and who made me meet my wife, Débora, with whom we raised a wonderful family (they are all sitting there with their boyfriends and girlfriends). In 2005, I had to tell Dr. Pellegrini that I was not going to rotate in his service because I had lymphoma; he thought I was just another Argentine telling him a lie, but I told him that when I got cured of the lymphoma, I would rotate with him. Dr. Rosenthal was also there and he told me he would help me with the examination of the biopsy specimen.

But what is most important is that I owe a debt of gratitude to professionals, colleagues, board of directors, patients, but most of all to my family. Family is the most important thing. Walking the road of surgery and getting a patient to trust us is very difficult, it is a long road and sometimes the time one has to spend with the patient means less time with our family. So I simply want to apologize for taking a lot of time away from you in the smallest things; for example, maybe I told you fewer tales than I should have told and played fewer games than I could have played, but you had a very good mother who was capable of filling all those spaces and supporting you to become the persons of integrity that you are today.

The truth is that, when a patient gets complicated, one may be sitting at the table or maybe at home, but one’s mind is elsewhere; however, when a child fails or suffers, we feel even worse. Let’s take care of our family, let’s take care of our children and let’s love our patients very much. Thank you very much.