Will surgery remain an option?

[Handsome88]

I'm a preclinical student so I still have to decide between Surgery or Medicine.
I've been speaking with several doctors from both fields. And both have been telling me that soon surgery will be 'less needed' than it is now, as medical treatments and non-invasive procedures are advancing quickly that surgery will rarely become an option.
I want the opinion of people here. How true is this?

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[SLUser11]

I'm a preclinical student so I still have to decide between Surgery or Medicine.
I've been speaking with several doctors from both fields. And both have been telling me that soon surgery will be 'less needed' than it is now, as medical treatments and non-invasive procedures are advancing quickly that surgery will rarely become an option.
I want the opinion of people here. How true is this?

It's true. You should go into medicine.






On a side note, I heard dentists are becoming obsolete because toothpaste is getting so good. Does anyone know if this is true?

 

[Handsome88]

It's true. You should go into medicine.






On a side note, I heard dentists are becoming obsolete because toothpaste is getting so good. Does anyone know if this is true?

Look, putting all jokes aside, if someone discovered a medical cure for cavities where teeth can rejuvenate, then pulling teeth out due to cavities will in fact become obsolete.

I know there are surgical procedures that will never be replaced by medical procedures (for example, I can't imagine hernia repairs being treated non-invasively). But generally speaking, will Surgery be less of an option with new advancements in Medicine (i.e. Interventional Radiology taking over vascular surgery).

 

[SLUser11]

Look, putting all jokes aside, if someone discovered a medical cure for cavities where teeth can rejuvenate, then pulling teeth out due to cavities will in fact become obsolete.

No, I know....you're right. I'm agreeing with you.

Seriously, you should go into internal medicine.

 

[Smurfette]

On a side note, I heard dentists are becoming obsolete because toothpaste is getting so good. Does anyone know if this is true?

They really do have some amazing fluoride options these days...

Seriously, asking a group of surgeons and surgery residents if they're about to become obsolete is not going to get you the answers you're looking for.

If there is a specific surgery specialty or procedure that you are wondering about becoming obsolete (i.e. "vascular" or "CT"), then that is different than asking if all types of surgery will be replaced by medical management. But I think there are enough surgical problems (free air, peritonitis, GSWs, cancers, obstructions of all sorts, hernias, hip fractures, burns, facial fractures, soft tissue infections) to keep many types of surgeons employed for a long time.

 

[Dr.LeoSpaceman]

They really do have some amazing fluoride options these days...

Seriously, asking a group of surgeons and surgery residents if they're about to become obsolete is not going to get you the answers you're looking for.

If there is a specific surgery specialty or procedure that you are wondering about becoming obsolete (i.e. "vascular" or "CT"), then that is different than asking if all types of surgery will be replaced by medical management. But I think there are enough surgical problems (free air, peritonitis, GSWs, cancers, obstructions of all sorts, hernias, hip fractures, burns, facial fractures, soft tissue infections) to keep many types of surgeons employed for a long time.

Not to mention the fact that you have to have someone around to manage the post-IR complications. Has anyone ever seen an IR attending admit someone or round on a patient?

 

[ACSurgeon]

I'm a preclinical student so I still have to decide between Surgery or Medicine.
I've been speaking with several doctors from both fields. And both have been telling me that soon surgery will be 'less needed' than it is now, as medical treatments and non-invasive procedures are advancing quickly that surgery will rarely become an option.
I want the opinion of people here. How true is this?

I'm really curious to know which "doctors" have been telling you this... I'd be even more curious to know which surgeons agreed.

To answer your questions, surgeons will be ballin till the end of time. No joke.

Also, IR is NOT replacing vascular surgery. Vascular surgeons were pretty smart about learning all the endovascular type stuff, and now most vascular surgeons do a mix of open and endovascular cases.

Finally, even for surgical problems that are now treated medically (peptic ulcer disease), surgeons are still occasionally needed (perf's, severe bleeds, etc).

 

[Handsome88]

They really do have some amazing fluoride options these days...

Seriously, asking a group of surgeons and surgery residents if they're about to become obsolete is not going to get you the answers you're looking for.

If there is a specific surgery specialty or procedure that you are wondering about becoming obsolete (i.e. "vascular" or "CT"), then that is different than asking if all types of surgery will be replaced by medical management. But I think there are enough surgical problems (free air, peritonitis, GSWs, cancers, obstructions of all sorts, hernias, hip fractures, burns, facial fractures, soft tissue infections) to keep many types of surgeons employed for a long time.

Sorry I didn't mean to make it sound like I'm asking if Surgeons will become obsolete. I was just wondering if you, practicing surgeons, are noticing such a trend where many of your bread and butter procedures are becoming a second, fall-back option, which are only used if the Medical treatment fails. I know there is a lot of research going into finding out different ways to reduce complications and morbidity, and I'm not sure if this means turning to non-invasive methods of treatment.

The surgeon I talked to was an ENT by the way.

 

[ACSurgeon]

Sorry I didn't mean to make it sound like I'm asking if Surgeons will become obsolete. I was just wondering if you, practicing surgeons, are noticing such a trend where many of your bread and butter procedures are becoming a second, fall-back option, which are only used if the Medical treatment fails. I know there is a lot of research going into finding out different ways to reduce complications and morbidity, and I'm not sure if this means turning to non-invasive methods of treatment.

The surgeon I talked to was an ENT by the way.

I like to think that ALL surgical procedures are "fall-back options." Boy you'd be hard pressed to defend why you operated on someone who can have been treated without surgery!

Sorry if I'm having too much fun at your expense!

 

[Handsome88]

Sorry if I'm having too much fun at your expense!

Well you are Alec Baldwin after all.

 

[45408]

But generally speaking, will Surgery be less of an option with new advancements in Medicine (i.e. Interventional Radiology taking over vascular surgery).

Where are you getting your information? From all that I've been seeing, it's the other way around. When you have a patient with claudication, you refer them to a vascular surgeon, not an interventional radiologist. All of our vascular surgeons do just about any angiogram that pertains to their territory (e.g., they don't do neurovascular cases) and any percutaneous intervention possible.

 

[Raygun77]

It will be interesting to see whether or not the whole oncology field could become the next 'peptic ulcer disease'- once firmly the domain of the surgeon, then treatable with pills.

Back in the day, and to a large extent today, curable = limited and operable for most solid tumours. Chemotherapy is still mainly mopping up the specks missed.

But huge amounts of work has been put into genomic analysis of cancers. It's been hard producing specific targeted therapies due to the fact cancers are heterogeneous- each one evolves differently, so so called biologics are still pretty crude (target VEGF or whatever everywhere). Maybe one day it will be cost effective, though, to produce specific vaccines or whatever to a person's individual cancer. Not saying it wouldn't be expensive, but hey so is surgery/radiotherapy etc.

I don't think the indications for surgical oncology have decreased just yet- big whacks do still occur and are pretty much mandatory for cure. But with things like radiosurgery and stage 1 lung cancer, and better targetted therapies- who knows??

Anyone have any thoughts about cancer surgery specifically? It's hard to say when/if the medical breakthrough will come around...

 

[bronx43]

Surgery will obviously be a necessary part of medical care for the foreseeable future. The question at hand is really about market share. I don't understand why people on this forum only stress about whether or not an entire field is going to be wiped out, because the likelihood of that occurring is small when you consider the myriad of procedures available to each surgical specialty. But, any changes in market share will be more than enough for certain fields to feel the effect. A decrease in market share could rapidly transform into a decrease in case load. And if the organizing bodies don't adequate control the number of graduates to mirror their market share, then it could lead to an equally rapid tightening of the job market. The erosion of CT surgery as a field is a perfect case study for this.

 

[womp]

There's always ortho trauma.

 

[dr.evil]

The honest answer is that it will evolve like it has for 75 years. Obsolete? Never. But rectal cancers may be chemo/rads only which is where it's headed. Same with several malignancies. PUD is much improved but I still have patients with perfs and bleeds.

Maybe new things will make surgery MORE prevalent such as transoral fundoplication for GERD. If that gets good, you're talking about a huge population who are miserable with GERD and don't want to take PPIs forever due to the osteoporosis or fundic gland polyps. Or bariatric surgery until someone invents a magic pill.

Things change. We evolve. Medical therapy is good for many things but has its side effects.

 

[sponch]

there'll always be something to operate on.

some things you can't fix once broken. you either need a replacement in terms of a transplant, prosthesis, or some kind of reconstruction.

plus we've learned our lesson about giving up procedures like coronary angiography and gut endoscopy to the fleas. the subspecialists jealously guard their turf. in some integrated cardiac and vascular programs, the residents are rotating through interventional cardiology and IR to learn those skills.

so even if everything went totally minimally invasive, surgeons may be the ones doing it. when i turn 50, it's going to be a colorectal surgeon doing my colonoscopy.

 

[DoctwoB]

so even if everything went totally minimally invasive, surgeons may be the ones doing it. when i turn 50, it's going to be a colorectal surgeon doing my colonoscopy.

I don't know about that. I agree that most surgical specialties have gotten wise and started placing a bigger emphasis on minimally invasive procedures and will largely prevent further encroachment on their turf. That being said it will be very difficult for CT surg to take back coronary stents from cards or colorectal to take back scoping from GI. The training, the providers, and the referrals are all in place for Cards/GI, and that will be very difficult to change.

 

[Handsome88]

The honest answer is that it will evolve like it has for 75 years. Obsolete? Never. But rectal cancers may be chemo/rads only which is where it's headed. Same with several malignancies. PUD is much improved but I still have patients with perfs and bleeds.

Maybe new things will make surgery MORE prevalent such as transoral fundoplication for GERD. If that gets good, you're talking about a huge population who are miserable with GERD and don't want to take PPIs forever due to the osteoporosis or fundic gland polyps. Or bariatric surgery until someone invents a magic pill.

Things change. We evolve. Medical therapy is good for many things but has its side effects.

Never said obsolete. But maybe a decrease in the number of operations they could do to help a patient. As others mentioned procedures are going to Cards/GI/Oncologists. These days you could figure out the problem without even opening up the patient (with the advancements in imaging techniques), then treat him non-invasively. Also with earlier discoveries of cancers and other diseases, removal of organs will not be as common as it is now. What I'm worried about is that in the future the only things that a surgeon might be able to do are 'repairs' (fractures, hernias, obstructions...etc).

 

[SLUser11]

But rectal cancers may be chemo/rads only which is where it's headed.

Maybe if the chemoXRT gets better, but not with our current stuff. While there may frequently be a complete clinical response, or even a complete metabolic response on PET, a complete pathologic response is still not common enough in rectal cancer to warrant complete non-operative management.

I do think that eventually there will be a more defined role for local excision after neoadjuvant chemoXRT.....TEMS or ASSPASS. Right now, the safe board answer is to do LAR/TME.

 

[filter07]

Let's get serious people.

ASSPASS is the future.

pro tip: don't search for that at work.

 

[dr.evil]

I do think that eventually there will be a more defined role for local excision after neoadjuvant chemoXRT.....TEMS or ASSPASS. Right now, the safe board answer is to do LAR/TME.

Of course. But we're trying to look into the crystal ball on this question. Chemo/rads for low rectal cancers is getting quite good. If I get rectal cancer, go through chemo/rads but the tumor is 1-2cm from the verge, have a complete clinical/PET response, I'm not having an APR, or coloanal anastomosis and likely not TME. Not initially but thats just me. I've taken out numerous rectal cancers after chemo/rads and no tumor exists on pathology.

This question about surgery numbers going down has been asked for the last 15 years especially in cardiac surgery.

The big problem is that medicine is tried first in a ton of diseases and then we operate on them when they have failed miserable. This is good medicine but hard on surgeons as we tend to get people that are worst case scenarios as they have been put through the ringer.

 

[McGillGrad]

Statistically, the most common surgeries by volume are repairing or removing something in/from the body. Invasive or non-invasive, a human being (or a robot proxy) has to peform the surgery.

Until you can teleport gallbladders and colons, surgeons will be around.

 

[SLUser11]

Until you can teleport gallbladders and colons, surgeons will be around.

I'm just going to train the robots to teleport them.

 

[dr.evil]

The thoughts in the medicine world is that a pill will be developed to dissolve gallstones, and a magical chemotherapy will arise that eradicates colon cancers, and antibiotics/perc drainage will eliminate most operations for diverticulitis.

Of course that's a stretch. Surgeons will be fine in our lifetime.

 

[MossPoh]

If surgeons can do definitive treatments, will we still need medicine for many diseases? Oh wait........

I feel like this is equivalent to back in the day when I did lots of coding. I'd go to debug (fix a problem), that problem would be fixed and then it'd uncover 3 more NEW problems. I wasn't very good at programming.

 

[dr.evil]

Surgeons and device makers are smart people. We realize that medicine has a lot of short falls where we can step in. I'm hoping the new Transoral Fundoplication has some promising long term studies as GERD is a MAJOR problem and I see far too many people on double dose PPIs chronically. Just an example of new mechanisms where we may be able to step in and step up

 

[IRGuru]

Start of by saying surgery will never be obsolete, obviously...just a couple points though

Not to mention the fact that you have to have someone around to manage the post-IR complications. Has anyone ever seen an IR attending admit someone or round on a patient?

I have...it happens very commonly. At my institution and MANY others around the country (UVA, VCU, UPenn, Hopkins, USC etc.), IRs have independent services, clinic time etc. and are services just like VS, cards where you have to put in a consult rather than put in an order for a procedure. The docs we work with love this since IR takes ownership of the patient (complications and all)... Most places over the next decade will transition to a clinical IR model (not the historically technical model you've seen). The reason for this is primarily a patient care/liability issue (the person who does the procedure SHOULD be the one to manage it and if they can't/don't know how, they shouldn't do it anymore).

Where are you getting your information? From all that I've been seeing, it's the other way around. When you have a patient with claudication, you refer them to a vascular surgeon, not an interventional radiologist. All of our vascular surgeons do just about any angiogram that pertains to their territory (e.g., they don't do neurovascular cases) and any percutaneous intervention possible.

This is very much dependent location...There are many many private practices and academic centers (ex. UVA) where IR's are true clinicians, see the patient in clinic, work them up and decide the next step and these types of IRs often get the first referral. In other situations, its a joint venture where both groups work very closely, MCW in Wisconsin is a great example of this. I can't blame you for not know that because unfortunately, if IR is not like this at your institution, it's very hard to realize it.

 

[HNANAL]

I'm a preclinical student so I still have to decide between Surgery or Medicine.
I've been speaking with several doctors from both fields. And both have been telling me that soon surgery will be 'less needed' than it is now, as medical treatments and non-invasive procedures are advancing quickly that surgery will rarely become an option.
I want the opinion of people here. How true is this?

by soon maybe like 200 years

 

[Alex57]

I think maybe you should wait until you get to third year and get on the floors. You could end up completely hating your surgery rotation and the field of surgery in which case all of your pondering at this point is sort of pointless.

I say this because I was told, and I firmly believe, that if you could see yourself doing anything else besides surgery, you should choose the other option. The residency and career require a lot of commitment. I would say even dedication in the face of uncertainty, including uncertainty about job security, health care reform, changes in reimbursement, etc. But, if you passionately love what you do, then it's worth it even if you are "less needed."

After you complete your surgery clerkship you'll have a better idea whether you love the field enough to make that commitment. Maybe I've been lucky and surrounded by enthusiastic surgeons who love what they do, but in my experience, I don't know of any surgeons who are "meh" about their profession.

Also, I'm not really sure an ENT is the most qualified to speak about the future of general surgery.

I guess in summary what I'm trying to say is, if this is an issue for you, then maybe you don't belong in surgery.

And I mean that in the nicest way possible. One of the best things about medical school is you still feel like your whole future is in front of you and you can be anything. You haven't committed to any specialty yet and closed off doors. Just chill for now, keep an open mind third year, be HONEST with yourself about who you are as a person and your priorities in life, and you will end up where you're meant to be.

 

[mmmcdowe]

If surgeons can do definitive treatments, will we still need medicine for many diseases? Oh wait.........

 

[Gfunk6]

Interesting thread. As a non-surgeon, I thought I would lend a few words of support for my surgical colleagues.

Maybe if the chemoXRT gets better, but not with our current stuff.

In my opinion, surgery is the curative procedure for the vast majority of GI malignancies. Adding chemo and XRT to the mix simply improves DFS.

From a radiation perspective, the main obstacle to an XRT only process for GI malignancies is the exquisite sensitivity of many GI structures to radiation. This is a major detriment in dose escalating to tumoricidal doses.

I do think that eventually there will be a more defined role for local excision after neoadjuvant chemoXRT.....TEMS or ASSPASS. Right now, the safe board answer is to do LAR/TME.

Not sure why you'd bother with a local excision if you'd be doing a LAR/TME. Seems like it would only be an issue if you had to do an APR.

 

[Buzz Me]

In my opinion, surgery is the curative procedure for the vast majority of GI malignancies. Adding chemo and XRT to the mix simply improves DFS.

Except for anal SCC. Or gastric lymphoma.

 

[JayDoc06]

I plan on spending my entire career at the end of many complicated algorithms. No matter how many boxes and arrows show up, there will always be plenty of patients who end up in our offices. The procedures change, the indications change, sometimes entirely new disease show up.

BTW rectal cancer might be one of the most complex (and interesting) algorithms that exists (therefore my career choice.) Young readers, don't get the idea that chemo/radiation just evaporates tumors into oblivion. That only happens sometimes, and we have no data about what happens to those patients if you follow them without surgery. For ALL solid organ tumors, the treatment is resection.

"Surgery" evolves, just like every other specialty. From now until most of us are done practicing, there will probably still be a shortage of surgeons.

 

[Gfunk6]

BTW rectal cancer might be one of the most complex (and interesting) algorithms that exists (therefore my career choice.) Young readers, don't get the idea that chemo/radiation just evaporates tumors into oblivion. That only happens sometimes, and we have no data about what happens to those patients if you follow them without surgery.

Great point. In the German Rectal Study, the pre-op chemoXRT pathologic complete response rate was only 8%.

 

[Zoom-Zoom]

Also, as medicine advances, so too will surgery. It may become increasingly easy to treat pt's with future meds, but it will also be easier to cure with physical intervention. So the ratio of med to surg treatment may not necessarily sway as dramatically as one might think. The only real risk I see is losing those interventional cases to "procedurists" as operations become easier, faster, less risky, and more automated (ie - interventional cards). I don't think this will be as significant of a risk to most of surgery as it has been to CT surgery, but still, it will be wise for surgeons to get on board with these advancements as they occur. Neurosurg is doing a great job with endovascular turf, for example...not that they necessarily need to worry about caseloads