Once the government's leading voice on health issues, the surgeon general faded into relative obscurity in recent years. When asked to name a surgeon general, many people can only recall Dr. C. Everett Koop - the famous Reagan appointee with the look and bearing of a biblical prophet.
Some thought that would change under the Obama administration, which early on considered popular CNN medical reporter Dr. Sanjay Gupta for the job.
Gupta withdrew and more than four months later, the Obama administration on Monday forwarded a new name - Dr. Regina Benjamin.
She has piled up an impressive list of accomplishments - she's the founder and savior of a rural Alabama clinic that was wiped out and resurrected three times by fire and hurricanes - but she's not well known and is an outsider to Washington.
Of course, Koop was an outsider too.
"Just because we don't know her doesn't mean she's not good," said Jeff Levi, executive director of Trust for America's Health, a Washington-based public health research organization.
The job of surgeon general was created in 1870 to oversee the reorganization of a government network of hospitals for sailors, which was in shambles. The first surgeon general adopted a military model, creating a cadre of uniformed government physicians that could be sent anywhere they were needed.
Those uniformed doctors became medical heroes. They figured out that malnutrition was causing the pellagra illness that plagued the American South. They confined a dangerous plague outbreak in San Francisco. They coordinated care for millions of Americans sickened by the deadly Spanish flu.
Meanwhile, the surgeon general's power grew, with oversight of such agencies as the National Institutes of Health and the Centers for Disease Control and Prevention as they came into being. For decades, surgeons general were chosen from within the ranks of federal public health agencies.
Perhaps the surgeon general to have the biggest impact was Dr. Luther Terry, who in 1964 released a report that was seen as the government's official confirmation that smoking causes lung cancer. It influenced millions to stop smoking.
"It was one of the most important public health reports or public health pronouncements in medical history," said Dr. Otis Brawley, the American Cancer Society's chief medical officer.
However, by the mid-1960s, some political leaders had grown discontented with the surgeon general's troops, believing they had dragged their feet in implementing Great Society programs like Medicare. A government reorganization in 1968 stripped the post of administrative powers, and since then the surgeon general mainly has been a health educator and spokesman, reporting to an assistant secretary of health and human services.
Even without the administrative powers, Koop made a huge splash in the 1980s. He attacked the tobacco industry, then became the government's chief health educator on the terrifying AIDS epidemic.
Koop bluntly dismissed the notion that it was a gay disease, saying AIDS was a non-discriminating contagion to be prevented through condom use and other measures. He also maneuvered around uncooperative Reagan administration officials in 1988 to send an educational AIDS pamphlet to more than 100 million U.S. households - the largest public health mailing ever done.
"You saw a surgeon general change the way our nation and the world dealt with an infectious disease," said Dr. Richard Carmona, who was surgeon general from 2002 through 2006.
Carmona, largely unknown, left office in 2006 when President Bush did not appoint him to a second term. In 2007, he testified to Congress that administration officials muzzled him.
Bills were introduced in Congress to prevent future political meddling, giving the surgeon general a budget and staff outside the control of the Health and Human Services Department. The bills died, however.
Last year, both the Institute of Medicine and Trust for America's Health called for a more prominent and powerful role for the surgeon general.
Public health experts say the person who holds the job is as important as the surrounding administrative framework. They say the surgeon general must boldly discuss what public health science dictates, even when political bosses disagree. Koop has said a surgeon general needs to be willing to walk away from the job to preserve that principle.
Some who know Benjamin say she can be soft-spoken at times, and is not likely to be the kind of firebrand that people remember in Koop and Dr. Joycelyn Elders. Some suggested Benjamin, 52, is more in the frank but lower-key style of another accomplished surgeon general, Dr. David Satcher, who served in the late 1990s and early 2000s.
In remarks at the White House Monday, Benjamin said Satcher was a mentor who led her into community medicine.
Her inspirational work at the Bayou La Batre Health Clinic in Alabama would no doubt help her as surgeon general, especially if she's used - as expected - to stump on the issue of health system reform, Levi said.
"She'll bring a front-line perspective you rarely hear in policy discussions," he said.