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Imagine there is no incision..

21 September 2021


An article by Mr David J O'Regan, Director of the Faculty of Surgical Trainers (FST)

Imagine there is no incision…. it’s easy if you try.

JA Beenes was the brilliant scientist who developed a blood clot in the brain. Using technology, he miniaturised a medical team of experts to enter his body and embark upon a Fantastic Voyage. This film was released on the 16 October 1966 – it is a classic submarine sci-fi adventure that stretched the bounds of the imagination. Lt. Tuck Pendelton, an American pilot, similarly took part in an experiment in 1987 where he is miniaturised inside a submarine-like craft to be injected into a rabbit, but instead, after shrinking, he is accidentally injected it into a hypochondriac's body.

Technology is advancing at a pace and every year brings something more exciting and novel. The fact that Q in the James Bond movies introduced the pager in Dr No, and the iPad used by the media magnet villain Elliott Carver in Tomorrow Never Dies, indicates the imaginations of films appear as reality over time. Dr McCoy in Star Trek uses a handheld gadget that combines all sort of diagnostic tools – indeed handheld ultrasound and ECG’s can be connected to the mobile device. Could Dr Spock’s device pick up the ‘ECG or Brainwaves’ of other organs as a diagnostic tool? Reiki practitioners sense disturbances without touch though colour changes and ancient Chinese medicine refers to ‘Chi’. Perhaps there is a lot more to it but our ability to measure and detect is not there yet?

There is a TED talk given by a renal transplant patient who connects live with his physician thousands of miles away who comments on the appearance of the renal cortex. Self-adhesive diagnostic plasters can determine and transmit physiological data for the post op patient. The future is now. All this is astounding and liberating for the patient and puts them more in charge of their health care.

So, what of the future? Well, you can now swallow a camera capsule that can takes pictures of the bowel without the need for endoscopy. Robotic surgery is here to stay, and the ‘operating surgeon’ can be on a console, again thousands of miles away. Laser incisions and immediate healing with ‘growth factor’ sprays, appear in many films. Miniaturisation is the goal of many in robotics.  It is very conceivable that the future will have nanobots – as in Dr Who – that are programmed to enter the body and deliver treatment – scientists have developed working controllable atomic scale nanobots!

The reason to list a treatise of films is to highlight the thinking. The question is what the surgeon will look like in the future.  Dr McCoy is a doctor – a gender neutral term that the RACS has adopted, and we must follow. What qualities are needed of the surgeon tomorrow and therefore what does this imply for the trainers?

Humility, compassion, fallibility, and empathy will still be needed as these are the human elements of being a doctor that no AI can emulate – computers will fail this Turing test. Curiosity, courage, and imagination will be the drivers of change. The surgeons of tomorrow will need to work and be able to communicate with multidisciplinary teams yet not conceived. Imagine working with teams of physicists, engineers, and chemists.

The ‘doctor’ will still offer diagnostics and provide intervention but on scales not yet imagined outside the theatre of entertainment. This will carry risks -it will carry a risk to the patient or even in the Fantastic Voyage risk to the ‘surgeon’. We are aware of that risk to ourselves today – at the turn of the nineteenth century it was acknowledged that up to five percent of any medical school intake would acquire and perhaps succumb to TB. 

In the case of the Fantastic Voyage, we will be required to extend our knowledge of anatomy and not look at it from an outside in perspective but also from an inside out perspective. This will require a future knowledge of 3D visualisation with or without google glasses.  Knowledge of anatomy, physiology and pathology will take on a new dimension at nano levels. The macrophage is a fearsome cell warranting prominence in any sci-fi movie!

So, if this is the future – and many would agree that we are on this trajectory – what is the roll of the surgical educator or trainer? The future has no limits. We need to recognise current limits of knowledge and forgo the text-translation tradition of teaching and inspire creativity, curiosity. We need to support and encourage, enquire and explore. Knowledge and the reason to acquire skills must come from within. When we consider a teacher and/ or trainer (I do not think either term fulfils a future role or provides definition) from this perspective they become a coach, a mentor, a partner, and sometimes even a candid friend. This is the transcendental nature of training – the pastoral care and holistic nature of letting someone be and enabling them to realise their best. This is what parenting is all about. It is about being a role model and instilling values and respect for our fellows. The requires honest candour. IT is also something that is hard to codify and score; but we can all recognise these skills and indeed the Silver Scalpel Award has been celebrating these attributes for twenty-one years.

This is the transcendental stage of education – it is in fact emancipation – a setting free from traditional education ideologies and propagated by institutions and dare I say our colleges. Yes, things are changing but the human spirt is crying for more. A good trainer should be seen as the vehicle for this change and one who inspires the next generation to question. ‘Why?’ is a powerful question that cultivates curiosity and enquiry. We need a system that promotes this sort of education and begins to value the true worth of a good trainer. These skills may be innate in some, but the behaviours can be learned and taught to the many. However, it does require support in the form of time, space, and recognition.

It is sad the education is not ubiquitously observed as one of the key strategies at all levels of the NHS. Moreover, the space to learn is being eroded and the time to learn is increasingly falling out with normal working hours. We are relying on the good will of trainers to set up training meetings before and after the working day and some even come in on their weekends off to deliver training. I noted this worrying trend in the recent citations for the Silver Scalpel Award – I worry that we are stumbling towards this becoming the normal and the Award is celebrating ‘the genuine but gullible trainer’. This has been exacerbated by COVID and the tension in the system will increase. We cannot afford to rely on this honest but ad hoc endeavour to secure the best for our future trainees. We need to act now to enable our good trainers. The system must change.

‘As a matter of fact, emancipatory education is the willingness to live meaningfully, creatively, and gracefully. It is the ability to identify and debunk diverse ideologies and practices of domination and seduction — say, the cult of narcissistic personalities that reduces democracy to a ritualistic act of “electing” one’s masters’ Avijit Pathak, Indian Express, 9 September 2021


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