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. 

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 😉

What I’ve learnt today at #SSAT19

On the first day of the #SSAT19 meeting, two of the most important take-home messages came from a a retired surgeon, Prof. Christopher Ellison:

  1. You’re only old once,
  2. You never retire too early.

Robin McLeod has reminded us that the role of women in surgery is… the same as it is for a man.

Alberto Ferreres has pointed out that surgery is a moral practice, guided by three values: self-sacrifice, altruism and unselfishness.

Sachiyo Nomura has showed us how it is possible to manage a perfect balance between workload and well being in Japan.

Finally, Bruno Silverstein has reflected on the moral injuries that surgery inflicts on surgeons and, subsequently, lead to burntout.