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Doing a lot with little – health care in Cuba
Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.
Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.
Although the Cuban government is a centralized, one-party state that follows the Marxist-Leninist ideology, every individual with whom we met answered our many questions with apparent candor. Perhaps our easy rapport was based to some degree on our common profession and our shared commitment to patient care. Although they were clearly proud of the quality of their free education and medical care, they were also quick to admit the shortcomings in their system: widespread poverty, shortages of food and advanced pharmaceuticals, and old medical facilities. We were not restricted in any way from moving around Havana or speaking with anyone, although our free time was admittedly limited because our busy schedule was crammed with at least two visits per day with the groups listed above.
We were interested in looking at how primary care was delivered in Cuba. We met with a primary care doctor in her office, which was situated on the ground floor of the apartment complex in which she and her patients lived. We also visited a polyclinic, two blocks from the primary care doctor’s office that serves as the next step up the chain and is the site where medical and surgical specialists come to consult with patients from 40-60 primary care practices clustered around the polyclinic. The walls of the polyclinic have posters that educate the patients about the importance of handwashing and prevention of hypertension and cancer. The polyclinic also has an epidemiologist who monitors such basic preventive services as immunizations and prenatal care, both of which achieve nearly 100% compliance in a society in which acceptance of these services is not optional. Pap smears are performed in the primary care clinics, as is comprehensive medical care.
As interesting and impressive as we found the primary care clinics, it was the visits with the surgeons in their hospitals that intrigued us the most. The surgeons we met were modest and collegial, yet proud of what they had accomplished under challenging resource constraints. The hospitals that we visited were reminiscent of the city and county hospitals in the United States in which many of us on the trip had trained in the 1970s: older facilities that were clean and serviceable, but with older, basic equipment. Nevertheless, C. Julian F. Ruiz Torres, MD, has developed minimally invasive surgery in a hospital dedicated to such technological advances. Although he is 72 years old, he still works tirelessly to obtain the resources to build a state-of-the-art surgical simulation center, now under construction. Basic minimally invasive surgical procedures are available in most hospitals, although advanced procedures are restricted to centers such as Dr. Ruiz Torres’ facility, Centro Nacional De Cirugia De Minimo Acceso, of which he is justifiably proud.
In the short time that we were in Cuba, we obviously could observe only a fraction of their entire system. We were unable to determine how representative the health care workers we met were; those we did meet, however, were committed, hard working, and idealistic. Their rewards are clearly not financial, as they are equally (and poorly) paid, earning the same $70/month, no matter what their “rank” in the system.
Whatever the political realities of life in Cuba may be outside of the medical setting, we connected with our fellow physicians and bonded over our shared passion for patient care. This trip was about meeting them and gaining some understanding of their professional challenges and their efforts to work with what they have. Their system has evolved in the unique cultural, political, and economic circumstances of Cuba, and so of course, such a system could never work here. And yet, it was refreshing and inspiring to see medical professionals dedicated to the ideals of our profession – serving the people by delivering the best care they could for all of their patients. My hat is off to them for accomplishing so much despite their limited resources.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.
Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.
Although the Cuban government is a centralized, one-party state that follows the Marxist-Leninist ideology, every individual with whom we met answered our many questions with apparent candor. Perhaps our easy rapport was based to some degree on our common profession and our shared commitment to patient care. Although they were clearly proud of the quality of their free education and medical care, they were also quick to admit the shortcomings in their system: widespread poverty, shortages of food and advanced pharmaceuticals, and old medical facilities. We were not restricted in any way from moving around Havana or speaking with anyone, although our free time was admittedly limited because our busy schedule was crammed with at least two visits per day with the groups listed above.
We were interested in looking at how primary care was delivered in Cuba. We met with a primary care doctor in her office, which was situated on the ground floor of the apartment complex in which she and her patients lived. We also visited a polyclinic, two blocks from the primary care doctor’s office that serves as the next step up the chain and is the site where medical and surgical specialists come to consult with patients from 40-60 primary care practices clustered around the polyclinic. The walls of the polyclinic have posters that educate the patients about the importance of handwashing and prevention of hypertension and cancer. The polyclinic also has an epidemiologist who monitors such basic preventive services as immunizations and prenatal care, both of which achieve nearly 100% compliance in a society in which acceptance of these services is not optional. Pap smears are performed in the primary care clinics, as is comprehensive medical care.
As interesting and impressive as we found the primary care clinics, it was the visits with the surgeons in their hospitals that intrigued us the most. The surgeons we met were modest and collegial, yet proud of what they had accomplished under challenging resource constraints. The hospitals that we visited were reminiscent of the city and county hospitals in the United States in which many of us on the trip had trained in the 1970s: older facilities that were clean and serviceable, but with older, basic equipment. Nevertheless, C. Julian F. Ruiz Torres, MD, has developed minimally invasive surgery in a hospital dedicated to such technological advances. Although he is 72 years old, he still works tirelessly to obtain the resources to build a state-of-the-art surgical simulation center, now under construction. Basic minimally invasive surgical procedures are available in most hospitals, although advanced procedures are restricted to centers such as Dr. Ruiz Torres’ facility, Centro Nacional De Cirugia De Minimo Acceso, of which he is justifiably proud.
In the short time that we were in Cuba, we obviously could observe only a fraction of their entire system. We were unable to determine how representative the health care workers we met were; those we did meet, however, were committed, hard working, and idealistic. Their rewards are clearly not financial, as they are equally (and poorly) paid, earning the same $70/month, no matter what their “rank” in the system.
Whatever the political realities of life in Cuba may be outside of the medical setting, we connected with our fellow physicians and bonded over our shared passion for patient care. This trip was about meeting them and gaining some understanding of their professional challenges and their efforts to work with what they have. Their system has evolved in the unique cultural, political, and economic circumstances of Cuba, and so of course, such a system could never work here. And yet, it was refreshing and inspiring to see medical professionals dedicated to the ideals of our profession – serving the people by delivering the best care they could for all of their patients. My hat is off to them for accomplishing so much despite their limited resources.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
Although Cuba lies less than 100 miles from the United States, we Americans tend to know far less about the island nation than about almost any other country in our hemisphere. Only since 2014 has the United States begun to allow its citizens to travel directly to Cuba and has opened official diplomatic relations, although direct trade still remains blocked.
Cuba’s health care system has been touted as providing universal access to primary care services, whose goals are promoting health and preventing disease as well as providing free medical education to a veritable army of health care workers. Less well known are the quality and standards of their surgical services.
Although the Cuban government is a centralized, one-party state that follows the Marxist-Leninist ideology, every individual with whom we met answered our many questions with apparent candor. Perhaps our easy rapport was based to some degree on our common profession and our shared commitment to patient care. Although they were clearly proud of the quality of their free education and medical care, they were also quick to admit the shortcomings in their system: widespread poverty, shortages of food and advanced pharmaceuticals, and old medical facilities. We were not restricted in any way from moving around Havana or speaking with anyone, although our free time was admittedly limited because our busy schedule was crammed with at least two visits per day with the groups listed above.
We were interested in looking at how primary care was delivered in Cuba. We met with a primary care doctor in her office, which was situated on the ground floor of the apartment complex in which she and her patients lived. We also visited a polyclinic, two blocks from the primary care doctor’s office that serves as the next step up the chain and is the site where medical and surgical specialists come to consult with patients from 40-60 primary care practices clustered around the polyclinic. The walls of the polyclinic have posters that educate the patients about the importance of handwashing and prevention of hypertension and cancer. The polyclinic also has an epidemiologist who monitors such basic preventive services as immunizations and prenatal care, both of which achieve nearly 100% compliance in a society in which acceptance of these services is not optional. Pap smears are performed in the primary care clinics, as is comprehensive medical care.
As interesting and impressive as we found the primary care clinics, it was the visits with the surgeons in their hospitals that intrigued us the most. The surgeons we met were modest and collegial, yet proud of what they had accomplished under challenging resource constraints. The hospitals that we visited were reminiscent of the city and county hospitals in the United States in which many of us on the trip had trained in the 1970s: older facilities that were clean and serviceable, but with older, basic equipment. Nevertheless, C. Julian F. Ruiz Torres, MD, has developed minimally invasive surgery in a hospital dedicated to such technological advances. Although he is 72 years old, he still works tirelessly to obtain the resources to build a state-of-the-art surgical simulation center, now under construction. Basic minimally invasive surgical procedures are available in most hospitals, although advanced procedures are restricted to centers such as Dr. Ruiz Torres’ facility, Centro Nacional De Cirugia De Minimo Acceso, of which he is justifiably proud.
In the short time that we were in Cuba, we obviously could observe only a fraction of their entire system. We were unable to determine how representative the health care workers we met were; those we did meet, however, were committed, hard working, and idealistic. Their rewards are clearly not financial, as they are equally (and poorly) paid, earning the same $70/month, no matter what their “rank” in the system.
Whatever the political realities of life in Cuba may be outside of the medical setting, we connected with our fellow physicians and bonded over our shared passion for patient care. This trip was about meeting them and gaining some understanding of their professional challenges and their efforts to work with what they have. Their system has evolved in the unique cultural, political, and economic circumstances of Cuba, and so of course, such a system could never work here. And yet, it was refreshing and inspiring to see medical professionals dedicated to the ideals of our profession – serving the people by delivering the best care they could for all of their patients. My hat is off to them for accomplishing so much despite their limited resources.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the coeditor of ACS Surgery News.
Strength in Community
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
No question about it, we are entering another uncertain time in health care.
Those of us of a “certain age” may yearn for a return to the days when we surgeons faced few restrictions on our practice or our decisions. Each of us has developed his/her own perspective on the state of U.S. health care and the best path forward, most frequently shaped by our background, geographical location, and practice environment. The tendency among a great many of us has been to erect walls rather than bridges and to view our own situation as unique and more threatened than that of others. Specialists and generalists, urbanites and rural dwellers, all tend to view their own worlds as uniquely challenging.
If there was ever a need to reach out and communicate with one another and understand that the overwhelming desire of every surgeon is to provide his/her patients with the best possible care, it is now. After all, we’re all surgeons who face the same sets of challenges in the OR. There is far more in our professional lives that unites us than separates us. It is critically important that surgeons maintain open lines of communication and solidarity, no matter what other characteristics of politics or place separate us. How do we accomplish this seemingly Herculean task in the midst of the dissension and disintegration occurring all around us?
One powerful tool that can help break down barriers to honest dialogue and reinforce solidarity among surgeons is the ACS Communities. This hugely successful communication platform, which grew out of the old ACS Rural List, is now an electronic meeting place and venue for dialogue for all members of the College. The Communities is a safe place where participants, despite their many differences in specialty, location, practice type, and political views, share the common goal of improving the care available to our patients. Postings range across a wide spectrum of topics – from clinical to fiscal, social, personal and philosophical, sometimes all in the same thread. All ACS Fellows are free to sign up and post on any subject that is of concern to them, as long as their postings adhere to a baseline respect for other members. The contributions are curated by Tyler G Hughes, MD, FACS, coeditor of ACS Surgery News, but they rarely stray from the boundaries of civil discourse.
The diversity of voices on the Communities is gratifying. Midcareer surgeons, recent grads, and retired specialists all converse with each other in this space. Surgeons from different practice types and locales, including from those who work in rural critical access hospitals and those in academic medical centers, all come to discuss, ask for opinions, exchange information, and debate. These colleagues offer opinions based on long years of practice and from article of the highest quality from the literature. The whole is somehow greater than the sum of its parts. Divergent opinions add depth and breadth to any conversation and lead to a greater understanding of the entirety of a subject. I always learn something from these dialogues.
Most threads involve questions about clinical issues that have arisen in the author’s practice. One recent topic was interval cholecystectomy in which the question was raised about whether the gallbladder needs to be removed after placement of a tube cholecystostomy (usually by Interventional Radiology) for acute cholecystitis, a practice that seems to be proliferating in many areas. Over a two-week period, responses poured in from a wide variety of practice sites and types and ranged from expert opinion to references from the literature. Other threads involve less commonly encountered conditions such as coccydynia or splenic cysts or offer opinions about such “hot-button” items” as attire in the OR or music in the OR. Almost every subject is interesting and provides the reader with food for thought.
Other topics stray from the purely clinical or surgical to the health care system itself. One current ongoing and timely subject of a thread on the ACS General Surgery community is entitled “Care for the Vulnerable vs. Cash for the Powerful.” Opinions have been expressed from many perspectives and have truly been educational and enlightening. While the general public discourse has been fraught and divisive, the Communities discussions have been respectful and collegial. This basic unity underlying our diversity is the foundation of the Communities and it is a source of strength for the surgical profession.
The ACS Communities is the work of many hands and hearts over many years, and I am truly grateful to those who made it happen and to the ACS for sponsoring this great platform for communication.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
From the Editors: The Clinical Congress: Something for everyone
In this issue of ACS Surgery News, you will see articles highlighting the program of the ACS Clinical Congress that took place in Washington, D.C., in mid-October.
This year’s theme, “The Best Surgical Education, All in One Place,” could not be more apt to represent the ACS Clinical Congress. And yet, the Clinical Congress is much, much more than an educational exercise for those who are able to attend. No matter what your age, whether it was your first time attending or, like me, your 41st, there is something at this meeting for everyone. Although the focus is on education, and the meeting does have a dizzying array of educational options, it is also an opportunity to see old friends and make new ones, connect with people with whom you share problems, work with colleagues to devise strategies to solve challenges, put faces with names you’ve only read about, participate in service and governance of our profession, and be inspired by the thoughtful leaders of our profession.
As the years pass by
I remember vividly my earliest ACS Clinical Congress, as a surgical resident at University of California, San Francisco, in October, 1975. It was 3 months into my research year and therefore I was able to attend the congress, which was in San Francisco that year. As one of the few women physicians in attendance at that meeting, I was in strange territory. I watched the opening ceremony with surgical leaders standing on stage, and I thought how homogeneous the group appeared: undeniably brilliant and accomplished, but all white-haired, white, and male. Fast-forward 41 years, and the surgical leaders who appeared on that stage at this year’s meeting were every bit as brilliant and accomplished, but the leaders are now younger and more diverse than in years past. The diversity in the college was evident as I walked the halls of the convention center where Fellows, residents, and guest physicians paused in their rushed transit from Hall D to Ballroom C to converse with an old or new friend.
The program itself has also become far more varied over the years. There is a continued emphasis on basic and clinical research in the scientific forum and scientific sessions. Postgraduate courses still impart new knowledge and skills, and state-of-the-art clinical practice is still taught in panel sessions. But the program now includes numerous nonclinical topics that are of crucial importance to present and future surgeons, such as ethics, end-of-life care, practice management, burnout, deciphering CMS regulations, and global health and humanitarian surgical outreach, to mention only a few. The named lectures continue to feature outstanding speakers who are often inspiring, and even sometimes provocative, and they are well worth attending. I would not want to have missed Past-President Carlos Pellegrini’s profoundly thoughtful John J. Conley Ethics and Philosophy Lecture on “TRUST: The Keystone of the Patient Physician Relationship,” for example.
Even the topics at the scientific forum have expanded over the years. In addition to the traditional basic science and clinical topics, five separate sessions this year on surgical education and on quality, safety, and outcomes attest to the increasing significance of these areas, unheard of when I was a resident. The important topics of ethics, geriatric surgery and palliative care, and global surgery/humanitarian outreach have gained sufficient interest that they now warrant their own sessions. There is something on the program to satisfy everyone’s interests. The forum presentations also provide us aging surgeons a chance to see the impressive contributions that our surgical progeny are making to the future of our profession. That, in itself, is encouraging and comforting.
Serving the profession
Many surgeons attend the congress in part to participate in committees of the ACS or other surgical organizations that meet during the congress to conserve time away from their “real jobs” as surgeons. These meetings offer attendees a chance to “give back” as well as to develop leadership in their profession. Participation in these committees can lead eventually to service on the Board of Governors or Regents, which offer opportunities to help shape the future of our organization and profession.
Profound positive changes in our profession have occurred through the leadership of the college. And some of these initiatives are reflected in the standing committees such as the Women in Surgery Committee, the Committee on Diversity Issues, and the Committee on Health Care Disparities, to name only three. Long-standing groups such as the Committee on Trauma (COT) have evolved greatly through the years and have raised the quality of trauma care and education in trauma across the United States and also globally.
Social and networking opportunities
The educational opportunities are unparalleled at the Clinical Congress, but the opportunities to connect with fellow surgeons is a close second. The chance to meet old friends from residency, recruit new partners for one’s practice, or be introduced to someone whom you have only known through postings on the ACS Communities are all invaluable aspects of the week. An email or telephone conversation is no substitute for these enriching face-to-face activities. And there is no substitute for this unique opportunity to create and extend your network of friends, colleagues, and allies. The Clinical Congress is often the beginning of relationships and professional connections that can last a lifetime.
Perhaps my enjoyment of the ACS Clinical Congress stems in part from how familiar it is after all these years and the comfort of being a member of this amazing organization. But my enthusiasm also comes from seeing how increasingly important and relevant the college has become to all of us – student, resident, Fellow, or guest. For surgeons, there is no substitute for the American College of Surgeons and there is indeed something for everyone at the Clinical Congress.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
In this issue of ACS Surgery News, you will see articles highlighting the program of the ACS Clinical Congress that took place in Washington, D.C., in mid-October.
This year’s theme, “The Best Surgical Education, All in One Place,” could not be more apt to represent the ACS Clinical Congress. And yet, the Clinical Congress is much, much more than an educational exercise for those who are able to attend. No matter what your age, whether it was your first time attending or, like me, your 41st, there is something at this meeting for everyone. Although the focus is on education, and the meeting does have a dizzying array of educational options, it is also an opportunity to see old friends and make new ones, connect with people with whom you share problems, work with colleagues to devise strategies to solve challenges, put faces with names you’ve only read about, participate in service and governance of our profession, and be inspired by the thoughtful leaders of our profession.
As the years pass by
I remember vividly my earliest ACS Clinical Congress, as a surgical resident at University of California, San Francisco, in October, 1975. It was 3 months into my research year and therefore I was able to attend the congress, which was in San Francisco that year. As one of the few women physicians in attendance at that meeting, I was in strange territory. I watched the opening ceremony with surgical leaders standing on stage, and I thought how homogeneous the group appeared: undeniably brilliant and accomplished, but all white-haired, white, and male. Fast-forward 41 years, and the surgical leaders who appeared on that stage at this year’s meeting were every bit as brilliant and accomplished, but the leaders are now younger and more diverse than in years past. The diversity in the college was evident as I walked the halls of the convention center where Fellows, residents, and guest physicians paused in their rushed transit from Hall D to Ballroom C to converse with an old or new friend.
The program itself has also become far more varied over the years. There is a continued emphasis on basic and clinical research in the scientific forum and scientific sessions. Postgraduate courses still impart new knowledge and skills, and state-of-the-art clinical practice is still taught in panel sessions. But the program now includes numerous nonclinical topics that are of crucial importance to present and future surgeons, such as ethics, end-of-life care, practice management, burnout, deciphering CMS regulations, and global health and humanitarian surgical outreach, to mention only a few. The named lectures continue to feature outstanding speakers who are often inspiring, and even sometimes provocative, and they are well worth attending. I would not want to have missed Past-President Carlos Pellegrini’s profoundly thoughtful John J. Conley Ethics and Philosophy Lecture on “TRUST: The Keystone of the Patient Physician Relationship,” for example.
Even the topics at the scientific forum have expanded over the years. In addition to the traditional basic science and clinical topics, five separate sessions this year on surgical education and on quality, safety, and outcomes attest to the increasing significance of these areas, unheard of when I was a resident. The important topics of ethics, geriatric surgery and palliative care, and global surgery/humanitarian outreach have gained sufficient interest that they now warrant their own sessions. There is something on the program to satisfy everyone’s interests. The forum presentations also provide us aging surgeons a chance to see the impressive contributions that our surgical progeny are making to the future of our profession. That, in itself, is encouraging and comforting.
Serving the profession
Many surgeons attend the congress in part to participate in committees of the ACS or other surgical organizations that meet during the congress to conserve time away from their “real jobs” as surgeons. These meetings offer attendees a chance to “give back” as well as to develop leadership in their profession. Participation in these committees can lead eventually to service on the Board of Governors or Regents, which offer opportunities to help shape the future of our organization and profession.
Profound positive changes in our profession have occurred through the leadership of the college. And some of these initiatives are reflected in the standing committees such as the Women in Surgery Committee, the Committee on Diversity Issues, and the Committee on Health Care Disparities, to name only three. Long-standing groups such as the Committee on Trauma (COT) have evolved greatly through the years and have raised the quality of trauma care and education in trauma across the United States and also globally.
Social and networking opportunities
The educational opportunities are unparalleled at the Clinical Congress, but the opportunities to connect with fellow surgeons is a close second. The chance to meet old friends from residency, recruit new partners for one’s practice, or be introduced to someone whom you have only known through postings on the ACS Communities are all invaluable aspects of the week. An email or telephone conversation is no substitute for these enriching face-to-face activities. And there is no substitute for this unique opportunity to create and extend your network of friends, colleagues, and allies. The Clinical Congress is often the beginning of relationships and professional connections that can last a lifetime.
Perhaps my enjoyment of the ACS Clinical Congress stems in part from how familiar it is after all these years and the comfort of being a member of this amazing organization. But my enthusiasm also comes from seeing how increasingly important and relevant the college has become to all of us – student, resident, Fellow, or guest. For surgeons, there is no substitute for the American College of Surgeons and there is indeed something for everyone at the Clinical Congress.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
In this issue of ACS Surgery News, you will see articles highlighting the program of the ACS Clinical Congress that took place in Washington, D.C., in mid-October.
This year’s theme, “The Best Surgical Education, All in One Place,” could not be more apt to represent the ACS Clinical Congress. And yet, the Clinical Congress is much, much more than an educational exercise for those who are able to attend. No matter what your age, whether it was your first time attending or, like me, your 41st, there is something at this meeting for everyone. Although the focus is on education, and the meeting does have a dizzying array of educational options, it is also an opportunity to see old friends and make new ones, connect with people with whom you share problems, work with colleagues to devise strategies to solve challenges, put faces with names you’ve only read about, participate in service and governance of our profession, and be inspired by the thoughtful leaders of our profession.
As the years pass by
I remember vividly my earliest ACS Clinical Congress, as a surgical resident at University of California, San Francisco, in October, 1975. It was 3 months into my research year and therefore I was able to attend the congress, which was in San Francisco that year. As one of the few women physicians in attendance at that meeting, I was in strange territory. I watched the opening ceremony with surgical leaders standing on stage, and I thought how homogeneous the group appeared: undeniably brilliant and accomplished, but all white-haired, white, and male. Fast-forward 41 years, and the surgical leaders who appeared on that stage at this year’s meeting were every bit as brilliant and accomplished, but the leaders are now younger and more diverse than in years past. The diversity in the college was evident as I walked the halls of the convention center where Fellows, residents, and guest physicians paused in their rushed transit from Hall D to Ballroom C to converse with an old or new friend.
The program itself has also become far more varied over the years. There is a continued emphasis on basic and clinical research in the scientific forum and scientific sessions. Postgraduate courses still impart new knowledge and skills, and state-of-the-art clinical practice is still taught in panel sessions. But the program now includes numerous nonclinical topics that are of crucial importance to present and future surgeons, such as ethics, end-of-life care, practice management, burnout, deciphering CMS regulations, and global health and humanitarian surgical outreach, to mention only a few. The named lectures continue to feature outstanding speakers who are often inspiring, and even sometimes provocative, and they are well worth attending. I would not want to have missed Past-President Carlos Pellegrini’s profoundly thoughtful John J. Conley Ethics and Philosophy Lecture on “TRUST: The Keystone of the Patient Physician Relationship,” for example.
Even the topics at the scientific forum have expanded over the years. In addition to the traditional basic science and clinical topics, five separate sessions this year on surgical education and on quality, safety, and outcomes attest to the increasing significance of these areas, unheard of when I was a resident. The important topics of ethics, geriatric surgery and palliative care, and global surgery/humanitarian outreach have gained sufficient interest that they now warrant their own sessions. There is something on the program to satisfy everyone’s interests. The forum presentations also provide us aging surgeons a chance to see the impressive contributions that our surgical progeny are making to the future of our profession. That, in itself, is encouraging and comforting.
Serving the profession
Many surgeons attend the congress in part to participate in committees of the ACS or other surgical organizations that meet during the congress to conserve time away from their “real jobs” as surgeons. These meetings offer attendees a chance to “give back” as well as to develop leadership in their profession. Participation in these committees can lead eventually to service on the Board of Governors or Regents, which offer opportunities to help shape the future of our organization and profession.
Profound positive changes in our profession have occurred through the leadership of the college. And some of these initiatives are reflected in the standing committees such as the Women in Surgery Committee, the Committee on Diversity Issues, and the Committee on Health Care Disparities, to name only three. Long-standing groups such as the Committee on Trauma (COT) have evolved greatly through the years and have raised the quality of trauma care and education in trauma across the United States and also globally.
Social and networking opportunities
The educational opportunities are unparalleled at the Clinical Congress, but the opportunities to connect with fellow surgeons is a close second. The chance to meet old friends from residency, recruit new partners for one’s practice, or be introduced to someone whom you have only known through postings on the ACS Communities are all invaluable aspects of the week. An email or telephone conversation is no substitute for these enriching face-to-face activities. And there is no substitute for this unique opportunity to create and extend your network of friends, colleagues, and allies. The Clinical Congress is often the beginning of relationships and professional connections that can last a lifetime.
Perhaps my enjoyment of the ACS Clinical Congress stems in part from how familiar it is after all these years and the comfort of being a member of this amazing organization. But my enthusiasm also comes from seeing how increasingly important and relevant the college has become to all of us – student, resident, Fellow, or guest. For surgeons, there is no substitute for the American College of Surgeons and there is indeed something for everyone at the Clinical Congress.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Coeditor of ACS Surgery News.
From the Editors: Querencia
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
In the flood of emails, periodicals, Twitter, Facebook, Doximity, Medscape, and other information that washes over surgeons every day, why should they use their precious time to read ACS Surgery News? That question is foremost in the minds of the editors of this publication as we consider news stories and commentaries for inclusion. Is this an article our readers are going to find informative, pertinent, and stimulating? We want ACS Surgery News to be a querencia: a source of reliable, vetted information that gives surgeons a place of intellectual security along the information highway.
The editors of ACS Surgery News understand surgery from the scrub sink up. While our mission includes keeping our readers informed about these looming thunderstorms, we are also privileged to report progress and innovations that keep coming no matter how the forces of red tape and commerce play against our profession. Bringing news of both challenges and beacons of hope for our profession with commentary and perspective from our colleagues is our objective. For the editors, this is both a mission and a pleasure. Since most of the editors and our Editorial Advisory Board (EAB), like our readers, must focus primarily on our jobs as surgeons, teachers, and researchers, we cannot read every journal or attend every meeting. The role of ACS Surgery News is to find the relevant news of interest and importance to surgeons, wherever it may be found, and to report it succinctly and accurately in a readable form. Before an article appears in ACS Surgery News, it is reviewed by the author of the paper or presentation for accuracy and reviewed by the most appropriate member of the EAB as well as by both Co-Editors for importance and relevance to our surgeon readers. We do not want to shy away from controversial topics, but endeavor to present such topics with balance and sensitivity, just as the ACS itself always attempts to do: to shed light, rather than merely heat, on all subjects that we cover in our pages.
The editors of ACS Surgery News hope that in the months and years to come, this publication can be a querencia for the surgeon: a safe and secure place to engage all the forces that a surgeon must confront to be successful. In these pages we hope you will find knowledge, wisdom, camaraderie, and support for your practice, whatever that may be.
Surgery is a life of great joy and great sorrow, sometimes happening all within the same hour. We hope to be part of the joy and to soften the sorrow by being a publication you look forward to reading and wherein you find those things that contribute to your being a great surgeon and human being.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the Co-Editor of ACS Surgery News.
Dr. Hughes is clinical professor in the department of surgery and director of medical education at the Kansas University School of Medicine, Salina Campus, and Co-Editor of ACS Surgery News.
The future of surgery
Predicting the future has been a favorite topic of surgeons through the ages for addresses to august surgical societies.
Confident predictions of the future of surgery, however, have not always stood the test of time. Speaking at the University of Manchester’s Centenary celebration in 1973 at an international symposium on “Medicine in the 21st Century,” the noted surgeon J. Englebert Dunphy correctly predicted the prominence of joint-replacement procedures, but incorrectly asserted that medical advances would virtually eliminate the need for cholecystectomy through dissolution of gallstones and the need for surgical approaches to atherosclerosis through plaque prevention and dissolution. He accurately predicted that infections and sepsis would remain serious problems. But he missed the mark when he predicted that surgical pain would be eliminated by a pill that would block somatic nerve impulses without any respiratory or circulatory effects (Surgery. 1974 Mar;75:332-7). Technologic advances such as laparoscopic cholecystectomy, which emerged less than 20 years into the future, were not on his radar screen.
Change and disruptive technology
To be sure, the surgical procedures and methods have changed markedly since the time I trained in surgery in the 1970s. The most obvious change is the shift from large incisions to small ones, with the commensurate quick recovery and short hospital stays. This change is primarily because of the emergence of disruptive technology, a concept that has pervaded every avenue of our current lives, not just surgery: Think Uber, robotics in industry, the Internet, smartphones, and the miniaturization of just about every communication means. In medicine, these disruptive technologies have led to the emergence of the electronic health record, new imaging modalities, percutaneous interventional techniques, fiber optic endoscopy, laparoscopy, and endovascular surgery.
Maintaining capacity to do infrequent operations
During my training, H2 receptor antagonists and Helicobacter pylori came on the scene, with the result that ulcer operations almost disappeared from our surgical armamentarium; one of my most frequent operations as a senior and chief resident has become a rarity 40 years later for our trainees. And yet, a general surgeon must know how to perform an ulcer operation and which type is the best for a given circumstance, since perforated and bleeding ulcers are still seen, if infrequently. The perforated ulcer is seen most often in patients with multiple comorbidities who can least tolerate a complication and need one effective and well-executed operation if they are going to survive. How do we continue to teach residents these procedures when they have become infrequent?
There is perhaps some utility in keeping some aging surgeons around to teach residents on fresh cadavers, or to call them out of their assisted living facilities when needed for consultation! Now that the majority of operations in most places are being performed by minimally invasive surgical (MIS) methods, we may not need MIS fellowships or training much longer for trainees to become proficient in these skills, because it is the open operations that are less frequent. Our chief residents are much less secure about performing an open cholecystectomy, of which they have performed perhaps 5, than they are about performing laparoscopic cholecystectomy, of which they have performed 105.
Technologies on the verge of disrupting
Mark Aeder, MD, FACS, recently asked an important question in the ACS Communities thread on the future of surgery: What will the future disruptive innovations be? Which areas of surgery will bloom next?
There are many game-changing emerging technologies that could well turn out to be future “disruptors” of surgery as we know it. Cancer surgery is on track to be transformed by the development of genomics and personalized medicine and immunotherapy for melanoma and lung cancer.
The areas most likely to remain in the surgical realm are trauma, infections, and inflammation. Though safer cars, seatbelt laws, and helmet laws for motorcyclists have already decreased motor vehicle accidents and injury severity, we have still not produced a cure for stupidity or bad luck. Traumatic injuries will always be with us, and surgeons well trained in trauma management will continue to be needed. Appendicitis, cholecystitis, and diverticulitis will continue to require operations, even though inroads have begun with the studies showing success of antibiotic treatment for appendicitis and diverticulitis.
Keep current, avoid bandwagons
The key lesson, not only for our young surgeons-in-training but also for our seasoned surgeons, is to keep learning, keep networking, and keep adopting new techniques as soon as they show true evidence of success.
The best way for surgeons to remain prepared for whatever the future will bring is to stay current with innovations coming on the scene but not jump on the bandwagon too early and adopt new fads without substantial evidence of their soundness. A few retrospective case series reporting success with a new operation is insufficient evidence to try it out on the unsuspecting public. Although the completion of well-designed randomized trials with adequate follow-up takes time, it is better to stick with well-established and evidence-based techniques than rush to embrace an inadequately vetted procedure that may end up harming a patient.
Not all innovative devices or procedures rise to the level of being so truly “experimental” that they would require an institutional review board, and this ought to prompt an extra measure of caution by surgeons. Some “innovations,” such as the endobariatric devices reported elsewhere in this issue, represent novel variations of previous procedures but are as yet unvalidated by long-term studies. Responsible adoption of these novel procedures requires a full disclosure to the patient that the procedure or device is novel, without long-term evidence of success, and may entail unknown risks. Don’t let your enthusiasm to be an early adopter overcome your scientific and historic obligation to prevent harm to the patient.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the co-Editor of ACS Surgery News.
Predicting the future has been a favorite topic of surgeons through the ages for addresses to august surgical societies.
Confident predictions of the future of surgery, however, have not always stood the test of time. Speaking at the University of Manchester’s Centenary celebration in 1973 at an international symposium on “Medicine in the 21st Century,” the noted surgeon J. Englebert Dunphy correctly predicted the prominence of joint-replacement procedures, but incorrectly asserted that medical advances would virtually eliminate the need for cholecystectomy through dissolution of gallstones and the need for surgical approaches to atherosclerosis through plaque prevention and dissolution. He accurately predicted that infections and sepsis would remain serious problems. But he missed the mark when he predicted that surgical pain would be eliminated by a pill that would block somatic nerve impulses without any respiratory or circulatory effects (Surgery. 1974 Mar;75:332-7). Technologic advances such as laparoscopic cholecystectomy, which emerged less than 20 years into the future, were not on his radar screen.
Change and disruptive technology
To be sure, the surgical procedures and methods have changed markedly since the time I trained in surgery in the 1970s. The most obvious change is the shift from large incisions to small ones, with the commensurate quick recovery and short hospital stays. This change is primarily because of the emergence of disruptive technology, a concept that has pervaded every avenue of our current lives, not just surgery: Think Uber, robotics in industry, the Internet, smartphones, and the miniaturization of just about every communication means. In medicine, these disruptive technologies have led to the emergence of the electronic health record, new imaging modalities, percutaneous interventional techniques, fiber optic endoscopy, laparoscopy, and endovascular surgery.
Maintaining capacity to do infrequent operations
During my training, H2 receptor antagonists and Helicobacter pylori came on the scene, with the result that ulcer operations almost disappeared from our surgical armamentarium; one of my most frequent operations as a senior and chief resident has become a rarity 40 years later for our trainees. And yet, a general surgeon must know how to perform an ulcer operation and which type is the best for a given circumstance, since perforated and bleeding ulcers are still seen, if infrequently. The perforated ulcer is seen most often in patients with multiple comorbidities who can least tolerate a complication and need one effective and well-executed operation if they are going to survive. How do we continue to teach residents these procedures when they have become infrequent?
There is perhaps some utility in keeping some aging surgeons around to teach residents on fresh cadavers, or to call them out of their assisted living facilities when needed for consultation! Now that the majority of operations in most places are being performed by minimally invasive surgical (MIS) methods, we may not need MIS fellowships or training much longer for trainees to become proficient in these skills, because it is the open operations that are less frequent. Our chief residents are much less secure about performing an open cholecystectomy, of which they have performed perhaps 5, than they are about performing laparoscopic cholecystectomy, of which they have performed 105.
Technologies on the verge of disrupting
Mark Aeder, MD, FACS, recently asked an important question in the ACS Communities thread on the future of surgery: What will the future disruptive innovations be? Which areas of surgery will bloom next?
There are many game-changing emerging technologies that could well turn out to be future “disruptors” of surgery as we know it. Cancer surgery is on track to be transformed by the development of genomics and personalized medicine and immunotherapy for melanoma and lung cancer.
The areas most likely to remain in the surgical realm are trauma, infections, and inflammation. Though safer cars, seatbelt laws, and helmet laws for motorcyclists have already decreased motor vehicle accidents and injury severity, we have still not produced a cure for stupidity or bad luck. Traumatic injuries will always be with us, and surgeons well trained in trauma management will continue to be needed. Appendicitis, cholecystitis, and diverticulitis will continue to require operations, even though inroads have begun with the studies showing success of antibiotic treatment for appendicitis and diverticulitis.
Keep current, avoid bandwagons
The key lesson, not only for our young surgeons-in-training but also for our seasoned surgeons, is to keep learning, keep networking, and keep adopting new techniques as soon as they show true evidence of success.
The best way for surgeons to remain prepared for whatever the future will bring is to stay current with innovations coming on the scene but not jump on the bandwagon too early and adopt new fads without substantial evidence of their soundness. A few retrospective case series reporting success with a new operation is insufficient evidence to try it out on the unsuspecting public. Although the completion of well-designed randomized trials with adequate follow-up takes time, it is better to stick with well-established and evidence-based techniques than rush to embrace an inadequately vetted procedure that may end up harming a patient.
Not all innovative devices or procedures rise to the level of being so truly “experimental” that they would require an institutional review board, and this ought to prompt an extra measure of caution by surgeons. Some “innovations,” such as the endobariatric devices reported elsewhere in this issue, represent novel variations of previous procedures but are as yet unvalidated by long-term studies. Responsible adoption of these novel procedures requires a full disclosure to the patient that the procedure or device is novel, without long-term evidence of success, and may entail unknown risks. Don’t let your enthusiasm to be an early adopter overcome your scientific and historic obligation to prevent harm to the patient.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the co-Editor of ACS Surgery News.
Predicting the future has been a favorite topic of surgeons through the ages for addresses to august surgical societies.
Confident predictions of the future of surgery, however, have not always stood the test of time. Speaking at the University of Manchester’s Centenary celebration in 1973 at an international symposium on “Medicine in the 21st Century,” the noted surgeon J. Englebert Dunphy correctly predicted the prominence of joint-replacement procedures, but incorrectly asserted that medical advances would virtually eliminate the need for cholecystectomy through dissolution of gallstones and the need for surgical approaches to atherosclerosis through plaque prevention and dissolution. He accurately predicted that infections and sepsis would remain serious problems. But he missed the mark when he predicted that surgical pain would be eliminated by a pill that would block somatic nerve impulses without any respiratory or circulatory effects (Surgery. 1974 Mar;75:332-7). Technologic advances such as laparoscopic cholecystectomy, which emerged less than 20 years into the future, were not on his radar screen.
Change and disruptive technology
To be sure, the surgical procedures and methods have changed markedly since the time I trained in surgery in the 1970s. The most obvious change is the shift from large incisions to small ones, with the commensurate quick recovery and short hospital stays. This change is primarily because of the emergence of disruptive technology, a concept that has pervaded every avenue of our current lives, not just surgery: Think Uber, robotics in industry, the Internet, smartphones, and the miniaturization of just about every communication means. In medicine, these disruptive technologies have led to the emergence of the electronic health record, new imaging modalities, percutaneous interventional techniques, fiber optic endoscopy, laparoscopy, and endovascular surgery.
Maintaining capacity to do infrequent operations
During my training, H2 receptor antagonists and Helicobacter pylori came on the scene, with the result that ulcer operations almost disappeared from our surgical armamentarium; one of my most frequent operations as a senior and chief resident has become a rarity 40 years later for our trainees. And yet, a general surgeon must know how to perform an ulcer operation and which type is the best for a given circumstance, since perforated and bleeding ulcers are still seen, if infrequently. The perforated ulcer is seen most often in patients with multiple comorbidities who can least tolerate a complication and need one effective and well-executed operation if they are going to survive. How do we continue to teach residents these procedures when they have become infrequent?
There is perhaps some utility in keeping some aging surgeons around to teach residents on fresh cadavers, or to call them out of their assisted living facilities when needed for consultation! Now that the majority of operations in most places are being performed by minimally invasive surgical (MIS) methods, we may not need MIS fellowships or training much longer for trainees to become proficient in these skills, because it is the open operations that are less frequent. Our chief residents are much less secure about performing an open cholecystectomy, of which they have performed perhaps 5, than they are about performing laparoscopic cholecystectomy, of which they have performed 105.
Technologies on the verge of disrupting
Mark Aeder, MD, FACS, recently asked an important question in the ACS Communities thread on the future of surgery: What will the future disruptive innovations be? Which areas of surgery will bloom next?
There are many game-changing emerging technologies that could well turn out to be future “disruptors” of surgery as we know it. Cancer surgery is on track to be transformed by the development of genomics and personalized medicine and immunotherapy for melanoma and lung cancer.
The areas most likely to remain in the surgical realm are trauma, infections, and inflammation. Though safer cars, seatbelt laws, and helmet laws for motorcyclists have already decreased motor vehicle accidents and injury severity, we have still not produced a cure for stupidity or bad luck. Traumatic injuries will always be with us, and surgeons well trained in trauma management will continue to be needed. Appendicitis, cholecystitis, and diverticulitis will continue to require operations, even though inroads have begun with the studies showing success of antibiotic treatment for appendicitis and diverticulitis.
Keep current, avoid bandwagons
The key lesson, not only for our young surgeons-in-training but also for our seasoned surgeons, is to keep learning, keep networking, and keep adopting new techniques as soon as they show true evidence of success.
The best way for surgeons to remain prepared for whatever the future will bring is to stay current with innovations coming on the scene but not jump on the bandwagon too early and adopt new fads without substantial evidence of their soundness. A few retrospective case series reporting success with a new operation is insufficient evidence to try it out on the unsuspecting public. Although the completion of well-designed randomized trials with adequate follow-up takes time, it is better to stick with well-established and evidence-based techniques than rush to embrace an inadequately vetted procedure that may end up harming a patient.
Not all innovative devices or procedures rise to the level of being so truly “experimental” that they would require an institutional review board, and this ought to prompt an extra measure of caution by surgeons. Some “innovations,” such as the endobariatric devices reported elsewhere in this issue, represent novel variations of previous procedures but are as yet unvalidated by long-term studies. Responsible adoption of these novel procedures requires a full disclosure to the patient that the procedure or device is novel, without long-term evidence of success, and may entail unknown risks. Don’t let your enthusiasm to be an early adopter overcome your scientific and historic obligation to prevent harm to the patient.
Dr. Deveney is professor of surgery and vice chair of education in the department of surgery, Oregon Health & Science University, Portland. She is the co-Editor of ACS Surgery News.