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The surgical future

More robots, less theatre work, more comorbidity and greater complexity in patients are all developments that future surgeons will have to face, the recent RCSI Millin Meeting heard.

The opening session of the Millin Meeting focused on ‘The shape of surgery — 2030’, with attendees hearing from experts about the growing influence of technology.

In spite of the futuristic perspective, there was also a focus on the familiar problems of capacity and waiting lists.

Speaking ahead of the Millin Meeting, RCSI President Mr Kenneth Mealy said society is now entering a really challenging annual period in health. “People who expect to undergo elective surgery over the next three months will have their surgeries cancelled because the hospital gets overcrowded.”

Mr Mealy said, “there is no quick fix to this problem but, long-term, we must separate acute and elective care in the hospital system so that elective surgeries are no longer vulnerable to cancellation during the winter months when the emergency system is under pressure. Putting the patient exclusively at the centre of our planning means there is no other outcome that makes sense. The Minister for Health’s [Simon Harris] recent visit to a scheduled care hospital in Scotland bodes well for the introduction of a similar model in Ireland and we fully support the Sláintecare proposals in this regard.”

Prof Deborah McNamara, Consultant General and Colorectal Surgeon, Beaumont Hospital, Dublin, and Co-Lead, National Clinical Programme in Surgery, HSE/RCSI, also spoke about current challenges facing surgeons.

“We have to start at where we are now. We really have to talk about delivering services at scale,” she told the meeting.

“Because our waiting lists show us that we are simply not doing that at the sort of scale necessary to meet the needs of Irish patients. Irish patients wait too long to have elective, scheduled or unscheduled surgery. And although we have made some progress in this area, the improvement is simply not at the pace fast enough for our patients.”

Prof Deborah McNamara

Prof McNamara said surgeons had done their part in improving the situation, but there needed to be ring-fenced funding.

“Surgeons have not been [found] wanting in trying to fix this problem; surgeons have delivered process improvements over the last seven years that have resulted in over a quarter of a million additional bed days every year being available to our health service,” she said.

“But process improvement is not enough in a system that is constrained by the insufficient surgical capacity and by highly variable access to scheduled surgery.”

Prof McNamara highlighted seasonal variation, in which “every winter surgical scheduled activity deteriorates, and that is the reason for waiting lists.”

“We need to find some ring-fenced elective capacity. I think it doesn’t really matter to most of us here whether that is a beautiful new hospital that you can see from outer space, or if it’s a repurposed second-hand hospital, whether it is a ‘big box’ IKEA-style build, or whether it is purchasing elective capacity from private providers. No matter how we deliver that additional capacity, we urgently need some ring-fenced elective capacity to meet the needs of Irish patients.”

Comorbidities

Prof McNamara outlined the ways in which patients that surgeons will see in the future will be different.

“Something that is really changing how we practice every day is what I would call ‘generation comorbidity’… comorbidity is the new normal,” she said. Prof McNamara said this was “adding to complexity”.

“In summary, emergency surgery in the future [will be] an awful lot more work, and a whole lot less operating. That’s a big change in how we practice.”

However, the patients will also be more informed, she added.

“Because whether we realise it or not, medicine changed forever on 29 June 2007, when the iPhone was launched, because now the knowledge that we once held uniquely in society is widely available for free to everyone,” said Prof McNamara. 

“That democratisation of knowledge has been said by some to mean the end of experts. I don’t agree with that. I don’t think that experts are gone; we need experts more than ever. But it has totally redefined the role of the expert.”

She told attendees at the Millin Meeting it was time to ask the question “what is a surgeon?”

“We also have to remember we have to deliver emergency rota, and there is a temptation always to appoint more and more surgeons to do that. But we also have to remember that those consultant surgeons need to maintain their competence as surgeons. And we have to balance those two competing demands.

“We need to be careful to balance consultant staffing levels to meet emergency rota needs with the critical volumes [of surgery] we need to be competent technicians.”

She added that “being only a technician is not the future of surgery; being a surgical expert is the future of surgery and that is a much more challenging role.”

Robots

The meeting was also addressed by Mr Richard Kerr, Chair of the Commission on the Future of Surgery, UK, and Consultant Neurosurgeon, John Radcliffe Hospital, Oxford, UK.

Mr Kerr outlined how he envisioned the role of technology growing in surgery.

“Firstly, the whole field of minimally-invasive surgery is going to continue to develop in the way it has been,” he said, “with perhaps the introduction of newer forms of minimally-invasive surgery using nanotechnology. Imaging will clearly continue to progress… with that, the world of augmented virtual reality will clearly become increasingly important.” He added that “training using 3D printing — I think you are going to see that as increasingly crucial”.

Mr Richard Kerr

In terms of stem cells, Mr Kerr said “there is concern that stem cells could be seen as being the technology that is going to solve a vast array of problems in the very near future. But I think that is probably not correct.”

He added that artificial intelligence will help in terms of diagnosis and robots will play a greater role.

“But will we be having robot-assisted surgery, or even automated robotic surgery [by 2030]? My view is that is probably very unlikely.”

However, he did not question the future importance of robots and said costs will come down.

“There is a new generation of robots expected to go on the market next year and I think the result of that will undoubtedly be that the cost of robots will come down and as a consequence, there will probably be more robots available for delivering treatments,” he said.

“If we go 20 years down the line, I think there are going to be specialist robotic centres. There may be situations where robots begin doing specific tasks, and do them autonomously.”

In terms of the lives of future surgeons, “we need to recognise that our roles in the future will be changing. Sometimes we will be the operator, but other times we will be the conductor, not the operator,” said Mr Kerr.

“While robots will always be a valuable, important, surgical tool, they are tools used by expert surgeons.

“The future of surgery, I think, will be evidence-based. It will be personalised; it will be minimally-invasive; it will be much more aimed at prevention rather than treating a disease. I think it is going to be team-based, based on digital technology. I think it is going to be based around informed patient consent.”

Structure

Prof Jan Sorensen, Director of the Healthcare Outcomes Research Centre, RCSI, spoke on the issue of healthcare economics and demographic projections for 2030.

He warned that any projections are problematic.

“The future is difficult to predict; it is worth doing, but it may not be accurate,” he told meeting attendees. 

“The current problems — there is no need to wait until 2030 to solve those, they can be solved now. Ireland is investing considerable resources and the question is whether the pay-off is sufficient. There are different ways of managing it… and improving the health of the population.”

He said he had travelled around a number of hospitals in Ireland and formed opinions on what could be improved.

Prof Jan Sorensen

“I can see a number of issues that need addressing. I think the management structure in the healthcare system is very centralised, and I think greater autonomy for hospital management would be one way of actually creating a more dynamic [system] and much more focus on efficiency,” he said.

“I am very keen on separation between the purchasing role and the providing role [at a hospital].”

Prof Arnold Hill, Head of the School of Medicine, RCSI, and General Breast and Endocrine Surgeon, Beaumont Hospital, spoke of the growing importance of the cancer centres in Ireland.

Looking towards 2030, he said “the delivery of surgical services will change. The 2030 surgeon will be much more specialised. I think the 2030 surgeon will do far fewer procedures. Cancer surgery will be centralised completely and there will be less hospitals doing emergency surgery”.

Alongside the discussion on the future of surgery, the Millin Meeting also focused on defining competence for the future surgeon. The RCSI launched an online course on professionalism for medical doctors in all specialties at the meeting. The final session of the day focused on producing surgeons fit for practice, featuring contributions from two surgical trainees.

The 41st Millin Lecture was delivered by Mr Padhraig F O’Loughlin on ‘New Technology in Orthopaedic Surgery’.

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