Invited post by Vahagn Nikolian: Telemedicine in the Future of Surgery

As wide spread adoption of technology has increased in our daily lives, so too has the arsenal of options physicians have to utilize and implement technology to take care of patients. Telemedicine, or the “use of electronic information and communication technologies to provide and support health care,” has resulted in improved access to care, increased resource efficiency, and decreased costs associated with routine health care. Given the promise for this resource, it is expected that the telemedicine market will demonstrate annual growth rates ranging between 20-50% for the foreseeable future.

Vahagn Nikolian MD – @VNikolian on Twitter
Fellow at @NYPHospital @ColumbiaSurgery Comprehensive Hernia Center

            Surgeons have utilized telemedicine in a variety of ways over the last decade. Pre- and post-operative patient evaluations utilizing telemedicine has become common in private practice and academic settings. Without a doubt, the accomplishments of the US Department of Veterans Affairs (VA) stands as the most impressive implementation of telemedicine technology. Annual VA Video Visits exceed more than 1 million regularly, with continued growth and allotment of resources expected for the next few years. Within the surgical patient population, the VA has demonstrated safety and feasibility in applying telemedicine to patients undergoing general, urologic, neurosurgical, plastic, obstetric, and gynecologic procedures.

            When considering new technologies, one must consider all stake holders and understand the impact that a deviation from the norm may have. Multiple studies analyzing patient satisfaction, time away from work, travel time, etc. have shown that patients are pleased with telemedicine encounters surrounding surgical care. Further, health care systems have demonstrated cost savings associated with implementation of telemedicine programs. For surgeons, telemedicine can provide an efficient means of evaluating patients and coordinating care. As the technology develops, utility in both rural and metropolitan settings must be assess to identify who would benefit most from these encounters.

            For telemedicine to continue to grow, concerns related to ethics of the platform must be scrutinized and overcome. The system must develop in a manner to ensure that health care data breaches are guarded against such that patients and providers are confident in the privacy and security of programs. Beyond cyber-security, other barriers hinder the widespread adoption of telemedicine platforms. First, licensure and practice laws for health professionals must be adopted that allow surgeons to more easily interact and take care of patients across state and, eventually, international borders. Additionally, reimbursement strategies must be reformatted to allow for patients to be evaluated without physically being in the same place as their provider. At the national level, enthusiasm for telemedicine is increasing, and reimbursement related to origination site requirements and definitions of rural qualifications have been updated to make telemedicine encounters more broadly applicable.

            In conclusion, telemedicine in surgery has received significant attention as patient satisfaction, decreased wait times, cost saving for both patients and health care systems have been demonstrated. With an emphasis on the patient and physician experience, telemedicine stands as an expected and natural evolution of surgical care. Moving forward, barriers at the local, regional, and national level must be overcome to allow for widespread dissemination and implementation of telemedicine in surgery. 

Entrada invitada: ¿Futuro de la cirugía en España? Por Sergio Sanchez-Cordero

Durante toda mi formación, he escuchado numerosos profesores explicar cómo iba a ser el siguiente curso, cuáles eran las dificultades y de qué manera iban a sucederse los acontecimientos hasta que consiguiera mi plaza en un hospital. Una vez entré a formar parte de un equipo quirúrgico, hablar de futuro es siempre hablar de incertidumbre. Nadie ha sido capaz desde entonces de aventurarse a determinar cómo será la medicina de aquí a cinco o diez años, cómo trabajaremos en los hospitales (incluso si trabajaremos en ellos) o qué actividad desarrollaremos en los quirófanos.

Sergio Sánchez-Cordero @sesanco – Residente de Cirugía

Actualmente, disponemos de un excelente sistema de salud, tenemos los mejores médicos en formación, los mejores instrumentos y el mejor entrenamiento que hemos tenido nunca, no obstante, las exigencias son mayores y a diario tenemos que manejar con el desequilibrio entre expectativa y realidad de nuestros pacientes. Así como la transformación de la cirugía abierta a la laparoscópica fue traumática para muchos, el futuro próximo revolucionará el marco en el que realizamos nuestra actividad quirúrgica. Por lo que, si una cosa tengo clara es que, la capacidad de adaptación al cambio es la característica más importante de los cirujanos en formación.

Por un lado, la cirugía basada en la seguridad del paciente y la calidad de vida va a producir un drástico impacto en la reducción de la iatrogenia en nuestros pacientes. El procesamiento de grandes cantidades de datos o “big data” y la inteligencia artificial aplicada, mejorará el conocimiento y monitorizará las consecuencias de nuestras acciones en los pacientes.  Si bien la formación de los cirujanos estuvo basada en el ensayo-error y el posterior análisis, la exigencia impuesta por la sociedad, no da margen de error a aquellos que por su condición de novel tienen más números de equivocarse. Por ello, se crearán plataformas y simuladores que se convertirán en un peaje durante la formación del residente. 

Si hablamos de innovación y cirugía, el Dr. J Marescaux, ya explicaba las revoluciones más inmediatas. Por un lado, la cirugía mínimamente invasiva, definida por plataformas robóticas, cirugía endoscópica y nuevas herramientas de acción quirúrgica que se están desarrollando, que hoy en día se encuentran en su expresión inicial, pero que irrumpirán en los quirófanos del futuro al tiempo que estaremos surcando la cresta de nuestra profesión. En segundo lugar, la integración y procesamiento de imágenes, tanto dentro como fuera de quirófano, el procesamiento de imagen a nivel molecular y la impresión en 3D, mejorarán la visibilidad de aquello que hoy vemos pero que nos abrirá la puerta a una realidad que actualmente no conocemos.

Y, por último, la revolución social afectará el modo en que nos relacionamos con el paciente y nuestros compañeros. Las plataformas digitales e interactivas y los sistemas de “telementoring” facilitarán la comunicación y la interconectividad entre los diferentes agentes del proceso. Investigación colaborativa, interacción con los pacientes, congresos online, etc. son algunas de las aplicaciones que nos encontraremos en un futuro próximo para beneficiar un mayor número de pacientes.

Por lo tanto, nos encontramos ante una nueva revolución que cambiará el escenario en el que estamos trabajando. Vienen épocas inciertas, con nuevos avances y recursos que dibujarán un escenario que, por ahora, es difícil de pronosticar. Nuestro objetivo como cirujanos es la adaptabilidad a un paradigma más “tecnológico” en el que seguiremos teniendo pacientes igual de “humanos”; con el reto de conectar una tecnología cada vez más inteligente y una humanidad cada vez más incomprensible.

Invited post by Ameera AlHasan: The future of surgery

“The best way to predict the future is to create it.”

Abraham Lincoln


Author: Ameera AlHasan, senior surgeon at Jaber Al-Ahmad Hospital, Kuwait

Surgery is an ancient craft that has withstood the test of time thus far. What the tides of the 21st century will bring can only be foretold by examining current trends and using them to steer our profession towards the future we hope to see.

Tweaking techniques through technology

As all aspects of modern life undergo a rigorous digitalization process, the practice of surgery is no exception.

Starting with minimally invasive surgery through the adoption of laparoscopy and robotics, surgical technology will continue to evolve in order to render operating a more comfortable experience for both surgeon and patient. The advent of human enhancement with advanced imaging and artificial intelligence means that the surgeon of the future will be able to see better and do more.

The improved understanding of the molecular basis of disease together with the advancement of nanotechnology has given birth to precision medicine. This novel field employs targeted therapy to address the subcellular, genetic and molecular determinants of disease. Speculations arise that this might completely obviate the need to operate on patients. Although this may be true at certain stages of a disease, it seems more likely that it will act as an adjunct, leading to a re-definition of the indications for surgery, and helping to create a multimodal approach to treatment of which one dimension will remain surgical.

Mending mental and mentorship models

The evolution of surgery from a mere apprenticeship into a science has led to the emergence of the “surgeon scientist”, an individual undergoing a metamorphosis from craftsman into profound thinker, dogma warrior and evidence generator.

As changes continue to occur in surgical culture and mentality, a dire call is being made for diversity, inclusivity and equity in surgery.  Once this is achieved, it will culminate in the creation of a melting pot brimming with talent, surgical prowess and novelty. The naturalization of women into the various fields of surgery is a leading example of how such inclusivity can capitalize on individual abilities to enhance overall performance and effect change.

Yet true revolutions can only be effectively brought about through conscientious mentorship. Mentorship has been crucial in the formation of surgeons across centuries, and the future will see a global plea for recruiting more surgical mentors. This is exactly where communication technology, social media networks and international associations will play a pivotal role in connecting mentors with mentees across the world.

Saving the surgical spirit

Finally, the question we’re all dying to ask is: Will we continue to operate?

The answer is YES, because that is what makes us who we are as surgeons.

However, in the face of technological advances and paradigm shifts, it will be crucial for the surgical community to foster a kindred spirit in order to continue to operate and prosper. The surgery of the future will no longer be a one-man/woman show as focus shifts onto coordinated teamwork and multidisciplinary management.  

Successful team management subsequently beckons for leadership as an indispensible skill for the thriving surgeon.

The quest has already begun to train and encourage surgeons to become leaders in the future, for the surgical messiah will not be chosen, but created.

Global Mentors – Mentores Globales

I was quite lucky. Not two, but three mentors I met along my training years.

  1. Jesús Alvarez Fernández-Represa
  2. Julio García-Aguilar
  3. Jeffrey B. Matthews

Being in the right place at the right time was the secret of my success. However, many others are not so lucky.

That is the reason why I have created a list on Twitter, which is directly related with the #SoMe4Surgery community: Global Mentors https://twitter.com/juliomayol/lists/global-mentors-surgery

Senior surgeons on Twitter who express their interest in becoming #GlobalMentors will be included in the list.

Surgical trainees just need to subscribe and connect with the #SoMe4Surgery mentors in the list.

No matter where in the world they are, trainees will find the right mentor to support their professional development. Mentors will find the right mentee.

With Jeffrey B. Matthews, J
ulio Garcia-Aguilar and Richard Hodin: the Boston’s Beth Israel Hospital/Hospital Clinico San Carlos Mentoring team

Value based surgery – the Journal of the ASGBI

Today, the Association of Surgeons of Great Britain and Ireland has published its Summer 2019 issue, including several contributions around a common topic: Value Based Surgery.

It has been an honour and a privilege to coordinate an outstanding group of surgeons, who have written thoughtful contributions regarding #Telemedicine, #PrecisionSurgery, #DigitalSurgery, #ERAS, and #Outcomes. The list of authors is as follows:

Muir Gray

Luis Sánchez-Guillen

Arfon Powell

Gemma Humm and Manish Chand

Mónica Millán

Rebecca Fish

I invite you to read their work here https://www.asgbi.org.uk/userfiles/file/journals/summer-2019-jasgbi.pdf

In order to transform the current practice of surgery into #ValuebasedSurgery, surgical leaders must address the following 5 common problems:

  1. Variability in quality and outcomes
  2. Harm
  3. Waste
  4. Inequities and Inequalities
  5. Lack of prevention

Coauthoring an article on #Valuebasedmedicine with Sir Muir Gray was particularly challenging, and funny. Quite an honour, and an unforgettable experience.

#SoMe4Trauma by Dr. Ameera AlHasan

Trauma takes numerous lives every year, in both a civilian and military setting. Trauma is the bread and butter of the general surgeon and the humble beginning of every specialized surgeon thereafter. It is therefore imperative to foster a strong online community that brings together efforts to raise awareness, share ideas and ultimately improve trauma practice on a global scale. This is how SoMe4Trauma was born.


Raised under the umbrella of the bigger SoMe4Surgery initiative, SoMe4Trauma aims to breed a community of trauma and acute care surgeons, other medical and non-medical trauma care providers (including ER doctors, nurses, EMS, fire brigade etc.), trauma policy advocates and trauma victims. Some of our goals include connecting the trauma community, sharing tacit & explicit knowledge, advancing trauma education, and creating a friendly and entertaining learning environment. In such a brief time period, the SoMe4Trauma family has managed to grow exponentially and to generate impact on Twitter. Such success can be attributed to a number of factors including the relevance of trauma to the medical community and the public (and the high burden of disease it represents), the unconditional support of influential surgeons on Twitter some of whom are true pioneers of trauma surgery and the continuous interaction of the SoMe4Trauma and SoMe4Surgery members.


Contrary to what it may seem, SoMe4Trauma is not a random tweeting service. The “behind the scenes” work that goes on in preparing most tweets is tremendous. That includes scheduling, networking, emailing guests back and forth, designing posters and recruiting tweeters to help interact and support the conversations. A structured approach is essential as real life efforts get translated into mere tweets. It is our belief that “failing to plan is planning to fail”. Real value can only be generated with vision and vigilance. 
             

Finally, just as management in the trauma bay depends on team work so does the sustenance of an online community like SoMe4Trauma. We invite you not only to interact with us, but to contribute and become a trauma leader yourself. All you have to do is to follow and use the hashtags #SoMe4Trauma and #SoMe4Surgery as SoMe4Trauma continues to blow your mind…hopefully, without causing any injuries 😉

Conectoma

Es posible que todo lo que termine haciendo nuestro cerebro al interpretar la realidad sea lo mismo, y visualicemos cada cosa que hacemos con elementos comunes .

Todo se nos parece a todo. Datos que pasan a información, que pasan a conocimiento, que pasan a ser patrones de comportamiento ante problemas similares (eso que llaman sabiduría). O intuición.

La complejidad de la red
Detalle de las conexiones y flujos de información en Twitter de las 500 cuentas más influyentes que se relación con la mía (punto azul de mayor tamaño). El punto azul más grande y más próximo es Steve Wexner

Cuando hace algo más de diez años comencé a utilizar Twitter, no parecía posible que, en tan poco tiempo, fuésemos a disponer de herramientas para capturar los flujos de información y las conexiones entre cuentas a un coste realmente asequible. No entre dos o tres cuentas, entre cientos de cuentas o miles de cuentas que representan a personas dentro de una plataforma.

Podían ser la representación de neuronas conectadas, podría ser la representación de aeropuertos y vuelos de conexión, o cualquier otra cosa. Pero siempre terminamos representando la realidad de una forma común y análoga. Tendemos a ver la realidad de una determinada manera y a aceptarla en su representación porque es la que nos gusta.

Global surgeons: Prof. O. James Garden

Edinburgh, 8th of June 2019, Prof. O. James Garden retires as chairman of the BJS Society.

Prof. Derek Alderson (left), president of the Royal College of Surgeons, and Prof. James Garden (right)

Looking back, I recall that on the 9th of May 2012, being Prof. O James Garden the honorary secretary of the BJS Society, I was appointed to the editorial board of the BJS. And over the following seven years I have had a meteoric career to become secretary of the BJS Society in June 2018.

Consequently, you might think that what I am about to say is biased, but I must warn you that you would be severely mistaken, because he has been the epitome of a global surgeon long before I even dreamed of becoming part of the BJS community.

Prof. O. J. Garden is an outstanding surgeon, researcher, educator and manager, but as you can read in The University of Edinburgh webpage, retired from clinical practice in the summer of 2018. Even so, he has remained committed to surgical research dissemination and global surgical training for longer.

Over the last two years, given my role as secretary, I have had the privilege of witnessing his chairmanship of the BJS Society. An extraordinary thinker and strategist, with a strong commitment towards the advancement of our two journals, BJS and BJS Open, and the promotion of global surgical training, James Garden will be deeply missed by all of us in the BJS Executive and Council, but be sure he will always be available if we need him.

Thanks a lot Prof. O.J. Garden. Live long and prosper.

Global surgeons

A brief reunion at #DDW19 in San Diego led me to give some thought to posting regularly about some surgeons who are currently in practice, no matter where in the world, and who I admire for their global impact on one or more of the following areas:

  1. Professional leadership
  2. Surgical research
  3. Education and training
  4. Technology and innovation
  5. Knowledge dissemination

So here I am, almost ready to start. Stay tuned for upcoming posts.

With Jeff Matthews, Julio García-Aguilar and Rich Hodin

What I’ve learnt on my second day at #SSAT19

Today has been an intense and long day at #SSAT19: plenary sessions, Foundation awards, presidential address, editorial board meeting, etc.

However, these are the things that come to my mind when I try to recall what I’ve learnt:

The SSAT must be transformed to meet new challenges and generate new opportunities for academic surgeons.

Obesity and bacteria are clearly linked. In mice.

IBD is linked to microbiota.

Bacteria have refined their genetic code for longer than humans. They may outsmart us.

Chemotherapy toxicity may be influenced by intestinal bacteria.

Microbiome may play a role in pancreatic cancer.

John Alverdy is THE expert surgeon in microbiome.

We must solve complex problems because the easy ones are already fixed (Marc Nivet)

Residents and younger surgeons include their Twitter handles in their presentations.

In order to achieve transformation one must challenge his/her biases, get comfortable with being uncomfortable, interrupt the usual, and be curious.