Dr. John Cameron, graying and slightly stooped, walks daily past a portrait of himself as a dark-haired young physician. The 1970 picture hangs in a Johns Hopkins Hospital corridor near his office. It is one among scores going back to 1890 that line these walls. Photo after photo shows the young doctors, nearly all men, as they completed training for careers in which surgical feats were expected.
Cameron, 69, is the product of the age in which surgeons dominated their hospitals. They revolutionized care, producing a cult of personality in which medical residents modeled themselves after those who had boldly made their marks.
Dr. William Halsted, the 117-year-old institution's first chief of surgery, founded the nation's first residency training program. Dr. Alfred Blalock, its third, helped pioneer an operation to repair babies' heart defects. Cameron, the fifth, modeled himself after both, perfecting a risky operation called the Whipple that remains the only available cure for pancreatic cancer.
But surgery's all-powerful role is waning. As he strives to secure his legacy, Cameron straddles the era that formed him and a new one he is helping to create. The surgeon is becoming a specialist who is but one part of a team of doctors that treats patients and researches diseases.
"Surgery is too late for most patients," Dr. Andrew Warshaw, chief of surgery at Massachusetts General Hospital, said about the pancreatic cancer operation for which he and Cameron are known. "We need another whole set of components to add to surgery. ... The world is increasingly becoming multidisciplinary, and you see that in a whole variety of fields."
Cameron's role in making Hopkins a leading site for pancreatic cancer treatment has bridged the old and new approaches. He embodies how medicine traditionally advanced at teaching hospitals - through everyday interactions with a powerful doctor. His habit-driven, egocentric style prompted others to help him improve postoperative care, keeping patients alive longer. The volume of his cases and the force of his personality helped attract a new generation of talent to research treatments.
Hopkins scientists have developed an experimental vaccine and ways to detect cancer sooner - discoveries based in part on study of tumors donated by hundreds of Whipple patients. Genetics experts are exploring the origins of pancreatic cancer and gathering information in a registry of patients' families. A radiation oncologist is among those starting a clinic in which many decisions will be made jointly.
"It used to be that surgeons were the senior people," said the vaccine researcher, Dr. Elizabeth Jaffee. She explained that a cadre of Hopkins scientists, most of whom are not surgeons, have gained international reputations in pancreatic cancer after being influenced by Cameron.
Their work becomes part of Cameron's legacy. Yet he keeps trying to secure his reputation in the time-honored way - through the survival of patients such as the aging judge on whom he operated in March and the skills of those whom he trains. He counts 11 proteges who went on to head surgery departments elsewhere.
Cameron hopes that Dr. Chris Sonnenday will be among the leaders. Cameron selected him as a resident nine years ago and has operated frequently with him during the past year. But for Sonnenday, who wants to continue in academic medicine, that schooling is no longer seen as enough. He needs to complete a fellowship to gain expertise in transplants.
He and Dr. Harry Zemon, assistant chiefs of service, will be among the last to have that top training position, which traces its roots to Halsted. Next year, in a reflection of the trend in academic medicine, the position will be abolished. A similar change is likely in coming years at Massachusetts General, Warshaw said.
"Surgical education is at the point of serious change, bigger change than it has had in more than 50 years or longer," he said. Nationally, surgical leaders are considering how to shorten basic clinical training so a doctor's preparation involves more time immersed in a medical niche.
At Hopkins, Dr. Julie Freischlag, who replaced Cameron as chair of surgery, has endorsed the new approach. It holds that - with most of surgery's major technical advances in the past - surgeons must become superspecialists who collaborate with other doctors and researchers to treat disease.
"He started it," Freischlag said, saying that Cameron worked closely with doctors who characterize tumors, interpret pictures of them or target them with radiation and drugs. But Freischlag is taking the concept further, changing the way that Hopkins educates and treats.
The team approach, she said, was "not what he wanted to be known for. He's done with his changes."
Cameron wants to be known as a technically masterful surgeon and teacher, particularly of the Whipple. He retains a boyish wonder at being able to fix the human body with his own hands.