Let’s look back to the future. Where were the frontiers of surgery at the start of your career?
Cardiac surgery was nearing its peak, and pancreatic surgery was a bit of a backwater; you didn’t see great outcomes, so many surgeons avoided it. But advances, particularly at Johns Hopkins and Massachusetts General hospitals, made the operation safer and left cancer patients with better results. We were able to make a lot of progress with pancreatic cancer over two decades, and it felt great to be part of that. That’s what stimulated my interest in pancreatic surgery.
Where are the comparable frontiers today?
The frontiers today lie in advancing procedures even further, to refine minimally invasive techniques. Seven years ago, people never imagined that the Whipple procedure or liver resections could be done laparoscopically, and now they are. Other frontiers lie in the areas of organ replacement and regeneration, either through transplantation or—what’s even more exciting—through efforts to build new organs from tissues and cells that are being engineered into functioning organs. Some are skeptical that these advances can be made, but people—including many at Massachusetts General Hospital and Harvard Medical School—are working to make it happen.
What’s the biggest hurdle?
Technology. Many new techniques require special levels of instrumentation and access that are still in development—robots, for example. Not everyone agrees that these techniques are worth the expense or even necessary. We need to be able to show that they’re as safe and effective as surgery done in an open fashion. Many of these operations still carry the risk of significant, sometimes even life–threatening, complications. When a safe open procedure is an option, we can’t introduce a technique that compromises patient safety just for the sake of being minimally invasive.
So how do we know when newer is better?
The best way to prove anything in medicine is through a randomized controlled trial. But that’s much harder with procedures than with, say, medications. Usually you’re trying something that you believe is better, and neither patients nor surgeons are willing to say, “I’ll take the old procedure, even though I believe the new one is safer.” So we compare our new results with our old results. We do an operation the new way 20 times, and then compare the results with those of 20 operations we did the old way. That’s good evidence, but it’s not the highest level of evidence. As a result, many new procedures never have supportive evidence that reaches the highest rung on that ladder.
What do you see as the future of surgical training?
Challenges in training residents include limitations on the hours they can work and the complexity of procedures. Hospitals are discharging patients faster, so residents have limited exposure to preoperative and postoperative care. How can we train residents to be efficient, so teaching doesn’t slow down a case or extend the duration of an operation? It’s called simulation. If residents can use simulation to refine their hand–eye coordination and learn surgical procedures before they enter an operating room, they’ll be better for it, and so will patients. We need to find a way for trainees to practice surgical techniques in a non–pressured, simulated environment, where they’re not hurting anybody or wasting time, but learning the steps they’ll need to take to ensure safe and successful operations.
Image: John Soares