In 1975, after finishing active duty in the United States Air Force during the Vietnam War, David Bouwman, M.D., joined the department of surgery at the Wayne State University School of Medicine in Detroit, as a midlevel resident. With one of the busiest emergency departments in the nation and home to several world-changing medical breakthroughs, including the development (with General Motors engineers) and use of the first successful heart pump in 1952, Wayne State was by no means a bad choice. But what clinched it for Bouwman was a four-month rotation with Choichi Sugawa, M.D., who had some of the first Olympus flexible endoscopes available in the United States and who ran the first surgical residency-training program.
That Bouwman was drawn by technology to a specific residency illustrates a commonly held hypothesis: Surgery progresses by opportunistically following technological developments. This hypothesis certainly applied, Bouwman notes, in the case of laparoscopy:
"When somebody had the insight to take one of the new, small, portable video chips and stick it on the end of the telescope we previously used for solitary-view laparoscopy, laparoscopic surgery became a team sport, and the coordination available opened up many, many procedures so that now for young people entering surgery, laparoscopy is a given part of the air we breathe. But 20 years ago, it wasn't even thought of."
As a resident, Bouwman saw the arrival of transcutaneous catheter introduction and the elimination of cut-downs for putting in Broviac catheters for chemotherapy. Today, Hickman catheters and even exchange transfusion catheters are going in transcutaneously without any problems.
The coming of laparoscopy was a huge dislocation, but there were others, such as percutaneous, endoscopically placed feeding tubes. Being extremely strong in flexible endoscopy training, Bouwman's residency cohorts were part of the first wave of adopters, using it in practice, to the betterment of patient care, long before off-the-shelf kits became available. The residents would put together their own kits and perform the operation. By such means and manner as this, technology that delivers value is quickly established as the new norm.
The Coming of RoboDoc
Does Bouwman think that surgical robots could deliver enough value to replace human surgeons?
"The coming of technology is always seen as the coming of the Borg in Star Trek — something that threatens to displace humans from our heritage. I don't think we have to worry about that. Being able to do more with machines is going to be the dominant future. I love science fiction, but have sworn off dysfunctional postapocalyptic novels because I don't think that's the way we are heading. Rather, we are heading toward an enabled, broadened future which quite possibly will benefit individual surgeons."
Bouwman and I both believe that machines eventually will take over surgery, not just because they will do a better job, but also because they will extend the scope and, therefore the future of surgery. This can happen with even the simplest technological innovation. Consider the humble hemostat — the clamp used on open vessels in the old days to prevent hemorrhaging (now largely replaced by ultrasonic and electrical coagulators). Before the hemostat, surgeons could not safely perform many procedures in which potential blood loss was a major factor. After it, they could. Like the heart pump, it was a major advance. It changed the game.
Another game changer during Bouwman's lifetime was the full development of the blood bank: "Before this era, a patient's coming into the hospital with a five- or six-unit exsanguination was a dead person. Now, they are routinely resuscitatable and you can get people through bloodflow shortfalls that you could not get them through before."
Another was hyperalimentation: "It didn't matter how good a surgeon you were: If you couldn't get your patient to eat within a week to 10 days, you had lost the battle because there was no way to replete the calories, and the patient would fall into a starvation pattern and develop complications leading to inevitable death. Now, we can maintain people almost indefinitely on hyperalimentation; its best usage being where it allows people to get through a period of time when their gut is not working."
Yet another: "Image-guided breast biopsy quickly eliminated the open surgical breast biopsy that used to represent 20 to 30 percent of the cases done in community general surgical practices."
The Rate of Change and Its Impacts
The rate of change in surgery is increasing, much like Moore's Law, to the point where many surgeons are afraid that the brute, operative approach to cures will give way to simple pharmaceutical or immunological manipulation. Bouwman and I prefer to look past this boundary, however. We believe that surgery, and surgeons with vision and with appropriate education, will leap across the boundary and grow into areas once unapproachable by surgery but now accessible because of new technology. We only have to look to Bouwman's 38 years in surgery to see that it has happened before.
Those years saw an increase in the acuity and seriousness of diseases that surgical residents are trained on and care for. As a midlevel resident in the mid-1970s, he routinely would admit 30 to 40 people to the hospital on a Sunday for three-day bowel preps for colon surgery that would take place in the middle of the week. Even gall bladder patients were admitted one or two days beforehand, to make sure they were prepared for the operation. Today, those admissions are all done the same day, and gall bladder surgery, along with many other operations, are outpatient procedures.
During his residency, Bouwman scrubbed as a second assistant on many cases. That meant there was a more senior resident as first assistant to the surgeon leading the case. So, one learned on the job first as an observer (second assistant), then as a partial participant (first assistant) and finally as an independent operator (attending surgeon). In today's world, such "double- or triple-scrubbing" is a luxury of the past.
Residents today frequently are asked to participate actively in types of cases they have never scrubbed on before. The time for reflection, the time to learn the craft, has been condensed not just by the 80-hour work week, but also by the amount of material that must be learned during the course of the residency.
It takes a different kind of surgical education — what Bouwman calls a sort of "nonclinical clinical education," which he explains as follows:
"We are now working on training for the skills that you are going to apply in the clinical arena by teaching the basic skill before your arrival in the clinical arena — in the simulation laboratory. This is the epitome of conformance to educational theory; that is, you get to practice in a safe environment and you get to make learning errors and no one pays the price (which might otherwise be morbidity for the patient and cost for the hospital, where OR time costs hundreds of dollars for 10-minute blocks). The days of allowing a resident to learn how to suture in the OR are gone. What we need is sim lab training that demonstrably transfers into the OR, and that's what I've been involved in for the past five years."
Education, he says, is not (or should not be) a finite journey to a short-term destination; rather, it is a lifelong process. This is vital if, over the course of a professional career, one wants to keep current with advances in one's profession. The half-life of usable knowledge in surgery is said to have fallen to around three and a half years, or so we have heard. If that is true, it means (in a very unscientific manner of speaking, but it makes the point) that:
- half of the surgical care provided by a top-flight resident will be outdated and perhaps not even standard of care within a mere three and a half years of completing residency;
- 75 percent will be outdated three or four years after that;
- by the end of a typical surgeon's 20 to 24 years in practice, only a tiny fraction of the care provided will be at or above standard.
We should not be surprised, then, if surgeons opt to retire early! If there were a continuous updating of skills, they might get to practice longer if they wanted to, and they certainly would have the enjoyment of providing (and their patients the benefit of receiving) state-of-the-art skills well after formal surgical training.
The Last Word
"We live in a modern world," Bouwman concludes. "We do our best to get our staff and trainees to adhere to the 80-hour work week rule. We hear residents long for the good old days when wonderful cases dropped like ripe fruit into their laps and many of them wish they had been born 25 years earlier. I say, 'No, the world was different then. It was very frustrating to have ill patients and not have the ICU technology to be able to keep them alive, to not have the antibiotics to be able to intervene effectively in their infections, to have no effective chemotherapy for cancers. It was an era with most things best left behind.'
"I am an optimist and believe we are making progress toward a better future so that all eras, including today's, will rightly get left behind if we continue to apply ourselves to gaining knowledge and skills. But most of all, we need to continue inspiring able young people to join our vision and our profession. They are the only hope for the future. After all, no one can practice forever or take care of every patient in need."
David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. He is also a regular contributor to H&HN Daily and a member of Speakers Express.