Divergent Vectors Impacting Modern Surgical Practice - Part 2

Interpreting my memory and experiences of the last half century, the more contemporaneous era of technology has replaced some of the manual art of surgery, using laser and cautery in many situations in place of the knife, scissor, clamps and ligature, staples replaced sutures for visceral repair. Administrators gained control of hospital systems. The profitable appeal of Centers of Excellence excited administrators who budgeted in favor of select procedures like cardiac surgery and joint replacement. Masters of Diagnosis in Internal Medicine became sub-specialists with one specialty expertise, many of which included technologic applications. Initially the growth of technology including sub specialization, then endoscopic techniques improved diagnosis and either replaced or complemented surgery. With further intraluminal technology, new procedures aiming to replace any incisional procedures were developed. Recently, Natural orifice surgery is now being developed to operate on intraperitoneal structure by panned perforation of hollow structures accessed via mouth, rectum, vagina. The theoretic planned perforation of a contaminated structure and minimal advantages over MIS is controversial. This new methodology is utilized more in Europe and Asia, but the market in the USA will stimulate illusionary need.

Most of this was beneficial, but unintended consequences followed.

As the 20th century closed, more dependence on technology resulted in less experience in open surgery in training and lost transference of the art and craft of surgery from the previous century. More diseases could be treated with less invasive procedures as early diagnosis of pathology radiologic and technologic advances facilitated the use of these less traumatic procedures which do have good results.

Branded as Minimally Invasive Surgery, MIS (actually minimized access surgery was still equally deeply invasive), like laparoscopy, robotics, endovascular surgery, intervention radiology, and Gastrointestinal and Pulmonary endoscopic techniques rapidly developed. This superb new technology was enthusiastically adopted, taught and expanded in all specialties and dominated to the extent that experience and skills in traditional open techniques lost out in training. In some situations, both methods were combined. A small percentage of surgeons applied advanced MIS techniques to more complicated problems.

Results were shown by some to be at least equivalent and frequently overall superior. Most senior surgeons skilled at both open and MIS knew that limiting injury to the abdominal and thoracic wall improved overall results and the patient experience. Their past expertise was applied to the majority of intracavitary problems and limitations based on complexity could be intuitively identified. Resident surgeons were and are taught the technology without having the experience in corresponding open procedures. Most of these advances occurred because of the enthusiasm, cooperation, organization and freedom with responsibility of experienced, skilled and prudent surgeons and endoscopist.

The present administrative trend is that selection of methodology and administrative support of new technology is stimulated greatly by the market value to competitive corporate hospital systems with medical technology companies marketing influencing choices in the market place.

However, complicated situations do evolve. Long term diseases can be advanced.

Acute processes can be critical. Technical expectations can be miscalculated.

There are always inherent failures, complications and recurrences of pathology that are not so amenable to the less invasive technology. Surgeries do occur after surgeries for many reasons and the abdomen and chest might not welcome the endoscope later in life. Subsequent reoperative surgeries for revision, recurrence, complication or new major regional pathology that hampers access and dissection by adhesions and distorted anatomy requires the older open methods or a combination of new and old techniques. Complications or extraordinary complexities during MIS require conversion to open methods. The circumstances and impact of comorbidities on physiology and anesthesia and pressure inflation of the abdominal cavity make these procedures more demanding and risky in selected circumstances, which will be increasing as patients survive longer and more surgeries are experienced.

Younger, recently trained Surgeons have not had as much opportunity to experience many of older techniques that were devised to handle historically complicated and advanced pathology encountered in the yesteryear. Many of their young mentors also lacked the experience in their training. There overall time of training has decreases about 50% due to regulations. Reading is dominated by the Internet over books and atlases.

So, from the general surgeon evolved the specialists, who wished to focus on a special interests, or in a limited comfort zone, or an improved life style, who spun off their limited specialties and developed Fellowships in those specialties. Their expertise is certainly beneficial but leaves them without tangent experience, knowledge and skills. Now, superimposed is a new demand for the more complicated procedures that were every day for the original General Surgeon but rarely experienced now.

There are fewer remaining Surgeons, Internist, Orthopedic surgeons, Neurosurgeons with the general experience, interest, training, broad specialization or interest than Leaders of the 20th Century. Some accomplished and prominent Sub-specialists are selected as Chairmen of Departments involving other specialties and more general practitioners and teach general surgery including diagnosis, technique and physiology. The corporation values their fame and profitable expertise. The depth of their support system might be limited by budgetary line item considerations. They render judgments on and regulate other specialties and their surgeons as if they still had expertise in those other specialties. These employed Chiefs must meet the metrics provided by managing corporate administrators who actually make budgetary decisions based on market value of certain procedures or modalities. These decision impact facility and equipment availability for less marketable services that are frequently critical or emergent in nature. Salaries and bonus depend on continued volume utilization of facilities. 80% of surgeons are employed by hospital and must meet imposed metrics. Voluntary surgeons, who are generally independent with successful practices based on past performance, provide facility usage with no institutional investment. This is the perfect business model providing facility reimbursement with no investment. These surgeons, although less “influential” and valued, continue teaching voluntarily to return the knowledge they have accrued to the next generation pro bono. Their talent is frequently squandered by the control minded Corporate system.

So who will teach open surgery?

Who will bridge the gaps between specialists?

Who will organize the team when multiple specialties are needed for complicated multi-systemic cases?

The older surgeons who spent decades doing open surgery have been displaced and eliminated by the present system or natural attrition.

We need to go back a bit to accommodate needs of the future.

Where have all the soldiers gone, long time passing?” (from “Where have all the flowers gone,” by Peter, Paul and Mary).

Part 3 to follow

A Semi-hyperbole: Quality Value gap results from surrealistic inversion and dialectic control of elite and intellectual Professionals by bureaucrats and lay management at multiple levels.

    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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