Surgery in the Twenty-First Century

Rembrant's The Anatomy Lesson of Dr Nicolaes TulpPrognostication is, by its very nature, a risky and uncertain endeavor. Yet a decent roadmap to the future is absolutely vital to the success of any enterprise, be it business or health care or personal finance. History can teach us a lot. Indeed the recent past is essentially the best barometer we have for what lies ahead. But what happens when the trend lines are disrupted?

This issue of FGA Index offers multiple perspectives on the evolution of surgery – a practice of curing disease via invasion of the body. Taking the long view reveals one of the most breathe-taking accomplishments of humankind while zeroing-in on recent game changers like minimally-invasive and interventional techniques sets the stage to consider what the future may hold.

Change, as the saying goes, is the only constant. Are you ready?

The Era of Anesthesia and Antisepsis

In the mid 19th century two key innovations – anesthesia and antisepsis – ushered in the era of modern surgery. Without these critical advancements the practice of surgery remained brutal and gruesome, truly, as Dr. Allan Brandt, Harvard Professor of History of Medicine puts it, “an intervention of last resort.” Dr. Brandt and others, including the writer and surgeon Atul Gawande, MD of Brigham and Women’s and surgeon Danny Jacob MD of Duke, share their insights on the evolution of modern surgery in the New England Journal of Medicine’s (NEJM’s) excellent documentary, From Rough to Refined: The Rise of Surgery. This video is part of NEJM’s series Getting Better: 200 Years of Medicine, produced in honor of the journal’s 200th year in print.

For those of us engaged in the day-to-day business of medical technology innovation, advancements in clinical practice can seem to move at snail’s pace. Indeed, Joseph Lister’s demonstration of antisepsis with carbolic acid met with overwhelming skepticism and it took nearly three decades for antiseptic and aseptic techniques to become accepted practice. Yet, as Gawande observes in his companion NEJM article, Two Hundred Years of Surgery, while “the benefits [are] only slowly and haltingly worked out” progress continues and even astounds, enabling surgical techniques to become “radically more effective . . . central to the development of mandkind’s ability to heal the sick.”

Modern Surgery: A Victim of Technological Progress?

Undoubtedly most surgical procedures performed a century ago would be unrecognizable to us today. That the practice of surgery is changing and will continue to do so comes as no surprise. Open, intra-abdominal procedures, once the bread-and-butter of general surgery, have declined in recent decades and one can only expect that such “maximally-invasive” procedures may become increasingly reserved for only the most complex cases.

In their July 2012 article Twenty-First Century Surgery: Have We Entered Uncharted Waters? Lawrence Rosenberg, MD and Thomas Schlich, MD argue, “the character of surgery is changing in a way that will make it difficult to maintain the traditional boundaries between surgical and nonsurgical treatment.” Citing recent technological breakthroughs in minimally-invasive instrumentation and imaging as well as advancements in our understanding of the molecular basis of disease, these authors maintain that surgery is presently at a “tipping point at which further innovation will jeopardize the surgeon’s traditional role.” They warn of a future of hyper-specialization where surgeons become “mere proceduralists” and encourage their surgeon colleagues to embrace alternative care models “where the division of labor is based on problems and organ systems and not on whether procedures involve cutting.”

The article serves as a call-out to today’s surgeons, urging them to adapt, to acquire skill sets needed to succeed in the new minimally-invasive paradigm, to become early adopters of new technologies rather than doubling-down on conventional enhancements, to take part in forging a new frontier in health care delivery. History tells us change will not likely come easy, the benefits of new ways “haltingly worked out” while skepticism, entrenchment, and turf wars ensue. Still, I am optimistic the trend lines are inching toward a positive future of greater efficiency, reduced costs and, the ultimate goal, better outcomes for patients.