Twenty-first century surgery: Have we entered uncharted waters?

Surgery is at an historic convergence of developments. As a result, the discipline as we have known it over the last 150 years may be in the earliest stages of dissolution—a victim of technological progress. Although this concept may seem somewhat paradoxical, given that surgery has always benefited from technologic advances, we may have reached the tipping point at which further innovation will jeopardize the surgeon’s traditional role.

Whereas in the past, technological breakthroughs often led to an increase in the number, scope, and complexity of surgical procedures, emerging technologies allow for smaller and fewer operations—a trend that will undoubtedly continue as devices become more sophisticated and miniaturized. Moreover, breakthroughs in our understanding of the molecular basis of disease, in imaging, and in instrumentation, along with the advent of energy-directed devices, will result in dramatic therapeutic advances, some of which are already making certain surgical treatments obsolete.1 The best example of this trend is the use of endoscopic retrograde cholangiopancreatography for common bile duct stones, but the advent of radiosurgery for early stage lung cancer and focal therapy for prostate cancer are on the immediate horizon.

Rise and fall of modern surgery

The rise of modern surgery was identified with the introduction of new operative procedures for treating diseases that had previously been treated medically or not at all.2 Classic examples include appendectomy and tonsillectomy, which marked the beginning of routine elective surgery on a mass scale; transplantation, which opened totally new prospects for the surgical cure of end-stage disease; radical mastectomy, which epitomized the notion that cancer could be cured surgically; and treatment of peptic ulcer disease through a potpourri of gastric procedures.3-6 These approaches have all changed significantly, with respect to their perceived necessity or due to the fact that the procedures have been downsized in scope, indication, or invasiveness.

In some fields, it was not only the introduction of new technology, but also the changing of criteria for effectiveness that has made surgery less attractive. Thus, the analysis of long-term outcomes has played to the disadvantage of some commonly performed procedures, as highlighted by the recent history of coronary bypass surgery.7 In a rather prominent Business Week article, a number of leading American cardiologists voiced the opinion that, except in a minority of patients with severe disease, coronary artery bypass surgery operations do not prolong life or prevent future heart attacks. These physicians went on to state that consideration should be given to retiring the procedure in light of equally efficacious pharmacological alternatives with or without stenting procedures performed by nonsurgeons.8

As a consequence of these technological changes, by the 1970s the steady increase of surgical operation rates leveled off.9 In the early 1980s, the number of operations performed per surgeon actually decreased by 25 percent.9 This drop occurred with a change in the spectrum of surgical interventions. Originally, in the 1970s, most general surgeons’ operating room time was spent performing intra-abdominal procedures. About one-quarter was expended on the three bread-and-butter operations—cholecystectomy and other biliary procedures, hernia repairs, and appendectomies. Many of these procedures were challenged and sometimes replaced over the past 20 years by radiologic and endoscopic treatments or by watchful waiting with or without antibiotics. These strategies either replaced open surgical interventions completely or significantly reduced their need. As a result, the surgeon was effectively removed, according to occupational sociologist James R. Zetka, “from the medical team that evaluated, diagnosed, and treated patients with such conditions. Holding the downstream position in health care delivery, and having much of their authority deflated during the period in question, general surgeons were powerless to reverse this course.”9

Furthermore, advanced imaging now extends beyond diagnosis into the interventional realm, too. The trend will move away from mechanical instruments of the Industrial Age to energy-directed instruments, including high-intensity focused ultrasound, thermal directed systems, microwave instruments, and femtosecond lasers.10

Disruptive innovation

The replacement of traditional surgery with new technologies is an example of “disruptive innovation,” a concept proposed by Harvard Business School professor Clayton Christensen to explain how otherwise well-managed organizations and professions fail to deal with technological change.11,12 Fundamental to this concept is the contrast between sustaining technology and disruptive technology. The former are highly developed, sophisticated, and comparatively expensive, and tend to target an existing market. Conventional open surgery is a sustaining technology. Minimally invasive procedures, including endovascular approaches, by contrast, represent disruptive technology, which are typically cheaper, simpler, and frequently more convenient to use. They initially target fringe markets, and market leaders often fail to take them up. It is precisely those practices that have allowed them to become industry leaders in the first place and that later make it extremely difficult for these leaders to develop the new technologies that ultimately steal their markets. It is important to realize that the failure to deal with disruptive technology does not stem from a lack of access or understanding of the technology itself, but rather from the organization’s structure and practices that preclude it from recognizing and investing in the disruptive technology until it is too late to compete successfully.11 Witness the recent decline of Research in Motion and Hewlett Packard in the face of the introduction of Apple’s iPhone and iPad products.

Mr. Zetka has examined the emergence of minimally invasive technologies and surgeons’ resistance to them in terms of skills disruption. He found that new technologies disrupted workplace routines and threatened surgical skills because the new skills were quite different than those surgeons had developed and used historically. The traditional surgical workplace was dominated by “a strong occupational culture that embraced the principles of surgical judgment, good hands, and large incisions.”9 The new technologies, by contrast, moved the site “of the surgical act from a direct, tactile environment to an abstract video screen environment.”9 This environment requires different interpretive and hand-eye coordination skills than traditional surgery. The experiential knowledge and the open surgery skills that surgeons had spent many years acquiring could not readily be applied to the new modality.

Surgeons often remained focused on their performance in open surgery and chose not to play a role in these new developments, leaving the development of new technology to their nonsurgical colleagues. This was, after all, how things had worked for a long time. Even distinguished academic surgeons thought “laparoscopic surgery was a fad, would never catch on, and had no place in modern surgical practice.”12

In cardiac surgery, technologies that were viewed as “too medical” were rejected in favor of more traditional surgical approaches that involved cutting and sewing.12 Cardiac surgeons had good reasons to resist change. In the early 1960s, the technological innovations of cardiopulmonary bypass and heart valve prostheses had led to the entrenchment of the specialty. The subsequent development of coronary bypass surgery as an effective anatomic treatment for the most common life-threatening disease in Western society resulted in an explosion in the number of cardiac operations performed.

“Cardiothoracic surgeons increasingly concentrated on a few, high volume, high intensity, high cost procedures with excellent financial return.”12 Moreover, the income that these standard cardiac procedures generated “fueled a dramatic expansion of the medical infrastructure in centers large and small throughout the United States.”13 Understandably, cardiac surgeons were reluctant “to tamper with success.”13 They hesitated to “devote time, training, and research resources to such non-traditional and disruptive technologies as angioplasty, percutaneous vascular grafts, and radio-frequency arrhythmia ablation.”12 In the meantime, angioplasty advanced steadily and transformed the interventional care of coronary artery disease to a point where fewer and fewer people require bypass surgery.8

The development of surgical techniques thus followed a typical sustaining technology path. Even though surgery had a history of constant innovation, the normal pattern had, in fact, been “more of the same.” Surgeons who developed new instruments, new techniques, and new procedures built on what they had learned previously. The new disruptive technologies in the late twentieth century were different. Often originating outside surgery, they required surgeons to abandon their old treatment paradigms. They also required new group-coordination strategies, which were “alien to surgeons’ ethos of individual responsibility and control.”9

Adjustment and competition

Eventually, surgeons in some fields felt compelled to change their orientation to include endoscopic technology because they were losing territory to the new competitors. Thus, during the 1980s, surgeons started embracing the gastrointestinal endoscope and staked claims over its operative applications. At that time, individual surgeons, often in community practice, made the first attempts at laparoscopic gallbladder removal. More and more U.S. general surgeons became interested and flocked to short courses to learn the procedure. This time, general surgeons countered the technological threat with a bold technological innovation of their own in the form of laparoscopic gallbladder removal.9 “After considerable turf losses over two decades, and in the face of challenges to one of their bread-and-butter procedures, general surgeons could, for the first time, offer a ‘minimally invasive’ procedure of their own to patients.”9 As Mr. Zetka notes, “Laparoscopic gallbladder surgery, more than any other development in the 1990s, helped to salvage general surgery’s market position and reputation.”9

It would take another 15 years for the laparoscopic tide to wash over most of the rest of conventional general surgery, disrupting surgical markets by shifting patient demand away from the established procedures. Many surgeons responded critically to these events and sought to restrict this technology to academic institutions and to controlled clinical trials.9

Laparoscopic techniques, however, do not belong to surgeons alone. Gastroenterologists (GIs) had established de facto control over the development of endoscopy long before the general surgeons became interested. Thus, surgeons were unable to dissuade primary care physicians from referring patients to GIs for endoscopic procedures. This reflected surgery’s structural weakness stemming from a downstream, referral-dependent position in health care delivery.9 In the end, surgery’s “belated attempt to incorporate endoscopy into the surgical armamentarium” had a modest effect at best.9 GIs remain potential competitors for control over the laparoscope. And the endoscopic approach to intra-abdominal surgery is likely to become the next battleground for surgeons and their nonsurgeon GI colleagues, should ongoing clinical trials demonstrate the technology to be safe and efficacious.14

Similarly, vascular surgeons, interventional cardiologists, and interventional radiologists can all claim expertise in managing thoracic aneurysms through endovascular technologies.15 Needless to say, these developments have resulted in increasingly vocal turf battles.16 Eventually, the vascular interventionalist may not even be a physician. A skilled interventionalist primarily requires video gaming skills that other health care professional could acquire with practice.

Over the last 20 years, “surgeons have found that they either must become competent providers of less invasive care or lose a significant portion of their patient base.”17

In light of all of these developments, surgical leaders have called for surgeons to adjust to “a future that involves the use of multiple technologies and in which rapid technological change is the norm….”11 “It was possible for a surgeon who finished training in the late 1970s to have a 20-year or 25-year career with very little alteration of their technical armamentarium, but that will never happen again.”13 Therefore, surgeons must become actively involved in new technology early on in the development and adoption lifecycle.18

New division of labor

In an effort to deal with the impact of the continuing evolution of technology, the profession could apply the business strategy of pursuing the first-mover advantage in order to dominate future markets. This would mean adopting new technologies as they emerge and making a major commitment to both upgrade the skills of the existing surgical workforce on an ongoing basis, and to establish credible programs of assessment to evaluate the comparative effectiveness of any new technology that comes along. However, acquisition and adoption of new skills usually entails giving up others.13 It is not entirely clear what the long-term effect of such a strategy would be, although it could very well lead to hyper-specialization and fragmentation.

Already specialization has greatly decreased the number of surgeons who can respond to trauma and surgical emergencies. This consequence is not because specialty surgeons are unwilling to treat such patients, but because they no longer feel competent in these areas.19

Surgical training must be long enough and rigorous enough for the trainee to acquire not only technical skills, but also certain intangibles. In his 2008 presidential address to the Society for Surgery of the Alimentary Tract, John Bowen, MD, FACS, warned that early specialization after only two or three years of general surgery “will produce a surgical workforce of narrowly trained specialists who lack the foundation, maturity, and breadth of experience to meet the challenges they will surely confront in their careers.”20,21

Super-specialization also carries the risk that surgeons will become mere technicians, something that has traditionally been anathema to the profession. It conjures up memories of the old subordinate role that the surgeon had in traditional Western medicine. The nineteenth century rise of surgery was based on the rejection of that role and the adoption of a new status as scientifically trained physicians who participate actively in the healing plan.2 By abandoning this successful strategy, surgeons could be downgraded to mere proceduralists.15

Another option would be to go back to the original values of a broader concept of general surgery, which gives surgeons an important role in disease management. For cardiac surgery, as an example, it has been suggested that practitioners should take on the role of the generalists because they are uniquely qualified to use multiple technologies to solve complex cardiac problems, including percutaneous technologies, whereas cardiologists are limited to that one technology.11

Furthermore, cardiovascular surgeons bring specialized expertise in managing the complications associated with new technology. They also have the judgment that comes with decades of experience and collective wisdom in operating in that area. “Most important, the cardiothoracic surgeon has the skills to differentiate which patients are most suitable for open chest procedures compared with endovascular approaches and understands that ‘by possessing a hammer, the entire world is not a nail.’”15

A more radical suggestion is Michael Porter’s notion of reorganizing medical practice around a model of “value-based health care delivery.”22 He argues that care should be organized around the way value is actually created. Today the health care system is organized around specialties, departments, interventions, and individual facilities, but value is actually created in the total care of a patient’s medical condition over the full cycle of treatment. Accordingly, Mr. Porter posits that care should be organized into integrated practice units (IPUs), encompassing all appropriate skills and specialties.

Surgeons may be part of an IPU, but do not alone determine value because they depend on others before and after a surgical intervention for the ultimate success of the care provided. In other words, high-value care is organized not by intervention and specialty, but around each medical condition. This means that the new division of labor would be based on problems and organ systems, and not on whether procedures involve cutting. Considering that “the distinction between cardiologist and cardiac surgeon based on the historical difference between internal medicine and surgery is increasingly obsolete,”12 the care of patients with cardiac disease and pulmonary disease could be completely reorganized. Instead of starting as surgical or medical residents, practitioners could start as cardiac practitioners to be trained “in a broad based environment which incorporates all aspects of cardiac disease including diagnosis, interventional radiology, interventional cardiology, electrophysiology, and cardiac surgery.”12 Members of this new specialty need not fear change in their field; they would be organized in a way that allowed adaptation to any technological change.12

The surgeon of the future

The impact of technological advances on the surgical profession during the waning years of the twentieth century and the early years of the twenty-first century is fundamentally different from earlier periods. Thomas R. Russell, MD, FACS, former Executive Director of the ACS, is right in saying that “the practice of surgery just isn’t what it used to be. [The] meaning of surgery has changed, driven by advances in technology.”17 However, it is the way technology transforms the field that is new.10 In fact, various disruptive technologies have been converging to fundamentally and irrevocably change surgery.20 Consequently, the character of surgery is changing in a way that will make it difficult to maintain the traditional boundaries between surgical and nonsurgical treatment.17

If these developments continue, surgery as we know it could well disintegrate. Surgeons will have to reinvent themselves.18 The professional strategy of investing in bigger and more sophisticated operative procedures that heralded the successful rise of surgery in the nineteenth and twentieth centuries is no longer applicable in the twenty-first century. The surgeon of the future will need to adapt and be able to learn a wider range of technologies quicker than ever before, a strategy that will profoundly influence the meaning of surgery as well as the professional identity of its practitioners.1,23 This approach may be seen as a chance for necessary adjustments, but it also entails risks, such as the widespread loss of general surgical skill, to the disadvantage of patients in need of such surgical competency. Therefore, today’s surgeons need to participate actively in shaping a health care delivery frontier in which they will still have a stake.


References

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