Applicant worries about the future of surgery

A medical student writes:

I am a few weeks away from applying for residency training in general surgery. Lately I've been lamenting that I was not born in the 1950s. I worry that the physician that I became enamored with so early in life is looking more and more like the surgeon I may never become.

Increasing enthusiasm for innovation in surgical technology is subtly paving a road toward a time in which a surgeon may be rendered obsolete. The rise of the two M's—machines and mid-levels—may herald a very different future from that which I ever imagined.

I love to solve problems and stand (not sit!) above an anesthetized patient making use of my hands and tools directly. There has never been a higher challenge than surgery which involves clinical skills in diagnosis, peri- and intraoperative disease management, and a sense of duty, service, and sacrifice. And now, robotics calls into question why hands might ever need to be laid on patients, and time-honored sutures are replaced with Silicon Valley-prescribed tinker toys.

Many articles call into question the relevance of physicians, particularly surgeons, in the not-too-distant future.

Will mid-level providers take away many general surgery cases? Will opportunities to function as a surgeon be threatened by the relentless emergence of technological or perhaps financial pressures? Are surgical societies actively confronting these issues?

I see you have thought about this in depth.

The PAs I have worked with did a lot of rounding, H&Ps, clinic work, and discharge summaries. In the OR, they assisted and closed skin. In some specialties, they do more such as harvesting vein grafts and closing fascia.

Here's an interesting anecdote about a PA who excised a neck mass by himself. He smelled it, said it was a benign sebaceous cyst, and threw it away. When the mass recurred, a surgeon biopsied it and found squamous cell carcinoma.

I don't see robots operating independently for quite a while, if ever, although NASA apparently has a robot that can be inserted into the abdomen and perform an appendectomy while being controlled remotely.

There is much variability in the location of the appendix, the inflammatory response, and the location of surrounding structures. How can a robot can ever be programmed to do this supposedly simple operation without human guidance?

If NASA has a miniature robot, it may be possible to control it while standing next to the patient. Having never seen it, I just don't know.

Surgery will undoubtedly change a lot in the next 40 or 50 years. As I wrote here, it certainly has since the 1970s. It might change at a faster rate too. But surgeons have adapted well, and they will continue to do so.

Surgical societies have not exactly shined during all of these changes. When laparoscopic general surgery was introduced in about 1990, mainstream surgical leaders called it heresy and were slow to catch up. Conversely, few said anything about the introduction and widespread acceptance of the da Vinci robot, which has not been shown to improve outcomes despite all the fanfare and expense.

Someone (the feds?) will have to put the brakes on unproven technologies or the country will go broke.

So if you want to be a surgeon, go for it, but be prepared for change.

A med student loves open surgery, asks about the future of pediatric surgery

Dimitar [not his real name] writes [edited for length]: I am a medical student who has already applied to the field of general surgery and finished the interview process. I hope to become a pediatric surgeon because it is one of the last fields that allows for one to operate all over the human body and to be a true general surgeon.

However I have been struggling with something that I hope you can help me with. I love the technical aspect of surgery. I enjoy becoming better at tying knots, suturing, and various surgical skills, and above all I love traditional open procedures. I like to feel with my hands and not with those laparoscopic instruments, I like to see with my own eyes and not through a tiny little camera all through a tiny little port. My biggest fear is that everything will become robotic, and that an open procedure will be a rarity in the future. And pediatric surgery most of all is basically an advanced laparoscopic fellowship. I want to make clear that I do not hate laparoscopy, I just enjoy the open procedures much more. I understand that this is probably a very selfish thought as laparoscopy has better recovery times, less pain, shorter hospital stay etc., but I guess that is why we have websites like this where I can ask anonymously what I am to ashamed to asked in public with hopes of getting a non-judgmental response.

To sum it up, I feel like I was born to do surgery back in 1950 or something when everything was open. I would like to find a field that would allow me to operate all over the body and do it the traditional way. Other than trauma, and transplant, what are my options? Would general surgery ever get back to what is was before? If I don't learn to love this laparoscopic and robotic thing am I screwed?

Those are very good questions. Let's start with your worry that pediatric surgery "is basically an advanced laparoscopic fellowship." I'm not so sure about that. If you look at the statistics for residents who finished pediatric surgery fellowships in 2013, you will find that many open cases are being done. This link gives you all the information you need. By my estimation, more than half of all pediatric surgery cases done by fellows were open. That's the good news.

For some bad news, you need to get the full text of this American Journal of Surgery paper that appeared online in November 2013. Written by some senior pediatric surgeons, it gives some worrying information about the specialty of pediatric surgery. The number of complex cases being done by attending pediatric surgeons has remained static while the number of pediatric surgeons has increased. It looks like many pediatric surgeons, even in university hospitals, aren't doing enough complex surgery.

The other bit of bad news is that competition for pediatric surgery fellowship positions remains intense. Here are some data from the last five matches.

As you can see the number of applicants for each position ranges from 1.5 to 2, and the number of unmatched applicants is rather high.

Trauma surgery is not the answer. There are so few open trauma cases being done that in order for trauma surgeons to maintain their skills, the specialty has morphed into "trauma, critical care, and acute care surgery."

I may be wrong, but I don't see general surgery ever returning to the old days where open surgery ruled. Not only that, I think in the future more and more cases will be done with minimally invasive techniques, even if the robot turns out to be a bust.

So in answer to your final question, I think you will have a problem if you do not learn to love the laparoscopic approach.

I wish you the best of luck.