A conversation on TED.com: What is the Future of Surgery, given that surgeons resist the costs (financial, training, proficiency) of radical changes in procedures?

Chuck Pell
Durham, NC
United States

Chief Science Officer, Physcient, Inc.

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What is the Future of Surgery, given that surgeons resist the costs (financial, training, proficiency) of radical changes in procedures?

Surgeons are highly proficient, well trained, seasoned adepts - so much so that complex procedures become automatic, fast, even symphonic. The same can be said of their surgical support teams. Asking these experienced professionals to change procedures greatly reduces proficiency, requires very long training times (months to get everyone back up to speed) and increases the chances for complications. How can we transform current tools (which dovetail with current training) into radically smart, agile instruments that greatly improve patient outcomes?

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Rafael Cabrales
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Feb 4 2012: Hi Chuck . I am a cardiac anesthesiologist with over 25 years in OR's as an attending , resident , student . The rate of change in surgery has not been slow . It is a completely different world than 25 years ago . It takes time to train people . You can develop the most sophisticated piece of equipment but the educational and training process for doctros is still the same as 50 years ago . Medical education , specialty training , exams , boards , accreditaion , licensing ,etc,etc,etc ..this process takes years and has not changed . As you said in your comment , a lot of the technically advanced procedures are only useful for a few type of cases . And even if you develop the most non-invasive technique in the world you still need to know how to do the traditional open approach as you will eventually run into trouble . We do a lot of robotic surgery at my institution and I am a proponent of advacing new technologies . I can assure you I am not impressed with robotic surgery with the exception of prostate surgery which we perform with 3d imaging . The surgeries may be cool with the robot but it doubles , triples and sometimes quadruples the lenght of the operation . Not only does it increase your surgical/anesthetic time ( do you want three times as much anesthesia just to get something out robotically that could have been taken out a much easier way with no statistically signiificant change in outcome ? I don't and I know about anesthesia!) Not only are the procedures longer but they require putting the patient in positions that are not physiologically possible for that period of time with serious stress to your cardiopulmonary system . Being head down in a 45 degree angle for 6 hours so we can use a robot has serious impiications to the anesthesiologist ( and to the patient) . Economically , if a surgeon wants to take out gallbladders all day with the robot he might do 3 in one day .His partner with the laparoscope will take out 6 in the same time .
Miles Price
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Jan 19 2012: DNA and RNA strands used in conjunction with machine learning applications to create nanomachines through self-assembly (no humans required) with a hybrid nanomachine/synethic life approach with a kill switch -- if you wish to know more, I can talk about it for hours with you

We are supposed to go through pharma and pharma may disappear or become personalized molecules. We are supposed to have artificial limbs built into us even with nanotube-latticed bone structures so that our bones become almost indestructable and well...it will be a matter of surgeons becoming obsolete or them being the basis of machine learning to view them as the experts so as to allow us to build upon the extremely advancd technologies which don't just manage diseases, but make them be consumed for energy to protect the rest of the body

All is possible with Catoms + Nanotech + Robotics + a new OS + biotech/genetics and even more advanced medicines utilizing string theory and quantum theory which we haven't stepped into yet.

Surgeons will have to know what would be best and shift paradigms and basically will become obsolete unless if they can learn to teach what they know to machines via machine learning (check out Andrew Ng's lecture on the future of robotics and machine learning) ad then GO from there
Vance Johnson 20+
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TED Attendee

Jan 16 2012: One of the main factors affecting the speed of change in a system is the speed of feedback.
If doctors could get outcomes/consequence feedback faster there would be greater pressure/incentive to change behavior.
My Dad, a spine surgeon now retired, cut open peoples backs to decompress their spinal canals. Today we would say his patients had long difficult recoveries. There are many surgeons still doing it the same old way.
I now do the same decompression through a 5mm portal under 3D guidance. My patients go home the same day able to do activities of daily living. The technology I use has been around for more than ten years but only about 400 doctors are using it in the USA for this purpose. It gives measurable feedback of decompression live during the operation. That feedback significantly directs my operation.
I have tracking systems to take in data on just about any part of the process and outcome I can think of.
I don't know which data sets will show useful trends so I observe widely.
Solution: Better faster feedback via simple graphic user interfaces.
- Chuck Pell
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  Jan 18 2012: I'd like to discuss this further - we're developing smart surgical instruments and your perspective would be appreciated, from more than one direction....
Chuck Pell
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Jan 13 2012: Maybe watching my TEDMED Talk will make things a little clearer:
http://www.tedmed.com/videos-info?name=Charles_Pell_at_TEDMED_2011&q=updated&year=all
Comment deleted
- Chuck Pell
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  Jan 13 2012: I agree - but the changed behaviors show up ten or twelve years later. There's another approach: improve the outcomes without asking the surgeons to change their procedures. The way I see forward is to put radically improved devices (that are roughly the same sizes and shapes as the old devices) into the hands of the surgeons that are operating every day - and, make them so similar to use, and so easy to learn, that the surgical teams can pick them up and begin using them on day 1. Check this out: http://www.tedmed.com/videos-info?name=Charles_Pell_at_TEDMED_2011&q=updated&year=all
  - Simon Tam
    
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    Jan 13 2012: I believe it's possible for people to adapt their methods. It's part of the profession. Some will and some won't...but the most effective surgeons will be the ones that get the most work, prestige, recognition, and appreciation.
    - Chuck Pell
      
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      Jan 13 2012: Certainly it's possible. The question is likelihood and speed. Surgical teams train until complex procedures are automatic, efficient, effective - and fast. Making these teams adapt isn't a small order - it takes Alpha types and throws them back into school, for months. Put another way, as the top revenue generators for most hospitals, open-heart teams are reluctant to exchange that status for "back-to-square-one" proficiency - and most agree that it takes 100 to 200 procedures to attain and retain proficiency in that single new MIS procedure. And they have to do this for every new procedure. And, new docs cannot skip open procedures - they have to be good at both in case the MIS needs to "convert."
      
      The procedures inside the chest are not the issue - the damage done by the 75-year-old (or *centuries* old) instruments to gain access *is.* The chest wall is heavily damaged by the old devices - and that leads to pain and suffering. If, on the other hand, one could gain access without the damage, then many of the benefits touted (but yet to be proven) for MIS would be in-hand - now, without the lengthy training. It's a win-win.
Chuck Pell
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Jan 13 2012: And, prevention is the key to improving almost every condition. That, and early detection. That said, many patients present with well-developed or late-stage conditions, and so require significant surgical intervention. For those millions, we need to upgrade the current surgical kit in ways that highly trained surgical teams can employ *immediately,* with minutes of training, not months. Drop the old steel before lunch, pick up the smart instruments after lunch, and immediately improve patient outcomes - by a mile - that's the near-term goal (18 months to market).
Chuck Pell
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Jan 13 2012: "The first step should call for more transparency on the direct and indirect costs due to surgical consequences such as chronic pain, loss of function and/or quality-of-life. Some of these consequences are accepted by the public and "system" as the norm but it ain't necessarily so."
Absolutely. For example, "cheap" steel surgical instruments are not judged by the horrendous, preventable after-effects of their use. Over half of the cost of traditional open-chest surgery, for example, is post-op care, some of which is Recovering From The Damage Caused By Access. MRI-guided ultrasonically generated thermal treatments can sidestep some of these effects (tougher around ribs and their associated steep density gradients and consequent lensing phenomena, but still).
Yoav Medan 20+
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TED Speaker TED Attendee

Jan 13 2012: Unless the healthcare system recognizes the cost of both short- and long-term morbidity due to use of "gold" surgical procedures, it will be very difficult to realize radical changes on a grand scale.

The first step should call for more transparency on the direct and indirect costs due to surgical consequences such as chronic pain, loss of function and/or quality-of-life. Some of these consequences are accepted by the public and "system" as the norm but it ain't necessarily so.
Simon Tam
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Jan 13 2012: Like any professional who is a leader in their field, the underlying theme is that you have to adapt or die. For the surgeons tied to archaic practices, they'll slowly lose their edge/credibility to those willing to embrace newer, more effective, and safer ways of doing things. This is especially true in medicine, as patients often have some choice as to how they want their procedure done (or if anything, the doctor's recommendation). Modern advancements allow surgeons and their teams more efficiency and often reduce surgery time sothere are definitely incentives to embrace new practices.

For instance, how many people still use an actual blade for lasik eye treatment over a laser? Some of the newest forms of cancer treatments don't involve radiation at all, but a pill (such as the Glevac pill which targets certain forms of leukemia).

If anything, there's always a new, upcoming generation of surgeons willing to embrace the new technology and use it to the fullest.
- Chuck Pell
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  Jan 13 2012: I guess what we're discussing here is the Rate Of Change. "Future" can mean too far to help someone with a diagnosis and a Deadline. I'd like to point out that (for chest surgery) we've had a mix of minimally invasive surgical techniques, VATS (video-assisted thoracoscopic surgery) and robotic (technically, teleoperated) surgery for thirty years, And, that we've published over 10,000 medical papers in the last ten years, And we've spent many billions of dollars in this area to promote minimally invasive surgery, And Yet: MIS + VATS + robotic *combined* accounts for less than 10% of chest surgery! Over 90% of chest surgery is open-chest. Change has stagnated, partly because MIS/VATS/robotic are useful for a few of the possible procedures required in the chest - And, if something goes wrong, one *must* be adept at open surgery anyway.
Amanda Carter
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Jan 13 2012: As much as I personally prefer non-surgical methods for healing, when it comes to must-have surgical procedures, I prefer the risk of human er, I believe the future of surgery is probably going towards nanotechnology and robotic surgeons. While we might lose touch with the human ability to heal with the hands, we will probably gain precision and better adaptability when it comes to "changing" procedures so often, which will let us learn more faster and lower complications.
- Chuck Pell
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  Jan 13 2012: A renowned thoracic surgeon (Flores, expert in VATS) stated from the stage at AATS 2011 that his most important surgical instrument was his finger. Touch isn't a magical thing, it's vital to confirm "ground truth" when faced with video imagery that may or may not be reliable. One must remember that machines are qualitatively and quantitatively far less adaptable than human hands. I believe some early cell-type discrimination and modification (or removal) may be achieved clinically with nanotech (actaully, micro- and meso- tech), but nothing like big steps: removing or implanting an entire heart-lung system. Now, I can see ways where microtech devices can assist (or alone) printing a working human heart in place, but the practical printing of a human heart is >3 years off, and clinally, 10 years off. Until then, millions of people will have their chests cracked open with rib spreaders designed in 1936. We can fix that now, in 2012 or 2013, without waiting for nanotech.
- Chuck Pell
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  Jan 13 2012: For the near-term, within months, try this approach: http://www.tedmed.com/videos-info?name=Charles_Pell_at_TEDMED_2011&q=updated&year=all