 Peter Angelos is the Linda Kohler Anderson Professor of Surgery, the Chief of Endocrine Surgery, and an Associate Director of the McLean Center here at the University. Peter is an expert in the surgery of thyroid, parathyroid, and adrenal glands, endocrine surgery. Since returning to the University of Chicago, where Peter had completed a McLean Ethics Fellowship from 1991 to 1992, Peter has emerged as one of the country's leaders in the field of surgical ethics, and in fact has brought the McLean Center into the forefront of that field. Peter is a member of the Ethics Committee of the American College of Surgeons and recently became co-director of a new Surgical Ethics Fellowship that's jointly sponsored by the McLean Center and by the American College of Surgeons. Peter is currently working on writing a text in Surgical Ethics and in editing another book also on Surgical Ethics. Today Peter will speak to us on the topic Surgical Ethics and the Future of Surgery. Peter Angelos. Thank you very much, Mark. It's a pleasure to be here. Thank you all for coming back for lunch. I also appreciate that. So I'm going to try to go rapidly through this because I feel the need to say a lot and yet I do want to allow some time for discussion. I have no disclosures, but I do have a few disclaimers and as Mark mentioned, I am an endocrine surgeon and so as an endocrine surgeon I primarily operate on thyroids and parathyroids occasionally on adrenal glands but primarily thyroids and parathyroids. So a translation of that is that I know an awful lot about very little and also my approach to medicine is different from many physicians who actually fix things and make them better. I actually can't fix anything. All I can do is take it out and so it's a different strategy. But anyway, so I will use examples that are related to thyroid surgery but I hope that you'll see them as examples that apply more broadly. The topic and I must say, Mark asked me if I would give a talk and of course I'm honored to be here and I wanted to give a talk that was appropriately vague that I could change it but also would suggest something about what it's about and so really this idea of what does the future of surgery hold is a great topic I think because the thing about the future is that as Niels Bohr said, prediction is very difficult especially about the future and no one remembers what you said today and so if in 10 years people say well let's look back and see what did Pietrangelo say. No one's going to do that because you all won't remember what I said. Number one and then even if you did remember who cares what I said 10 years in the future. So that's the beauty of talking about the future. That being said, I have a few suggestions about why I think surgical ethics is important and I'm going to start though talking about the future by talking a little bit about the past and so I want you to think back if you would to the fall of 1989 and if I were really good I would have pictures of me in the fall of 1989 as a surgical intern down the road at Northwestern Memorial Hospital. Fortunately there are no such pictures that exist and so it's not possible to show those but let me just tell you about an experience that I had that was sort of one of my early experiences with surgical innovation and you have to realize just biographically my father is a general surgeon in a small town in upstate New York, Platsburg, New York for those who know New York and if you know Platsburg we should talk because most people don't. So my father's a general surgeon at Platsburg and in late 1988, 1989 there's a lot of excitement in the field of general surgery about laparoscopic surgery. It was this new way of doing surgery with very small incisions and looking with scopes and it was really exciting and at Northwestern Memorial Hospital where I was an intern one of the surgical faculty had gone out and learned how to do this technique and a number of faculty were involved and so in the fall of 1989 I was one of the interns who was very excitedly looking forward to the very first laparoscopic colisostectomy that was going to be performed at the institution. Now you have to realize open colisostectomies the traditional operation was an operation that we did on a regular basis it was one of the most common operations done in America still is although now it's laparoscopic but in those days as and the way surgeons talk about it you talk about how long is an operation take well you want to know how long does it take skin to skin so that means from the time you make the incision until the time you close okay so skin to skin an open colisostectomy by an experienced surgeon was 30 minutes maybe 45 minutes if you're teaching institution an hour okay so so that's sort of the background and and I and a number of my intern junior resident colleagues were excited first case was scheduled patient was brought into the operating rooms asleep in the operating room now as you can imagine there are no residents anywhere near this patient there are three attending surgeons all scrubbed to do this very first case novel new operation now it had been done elsewhere obviously we weren't at the cutting edge but it was new for our institution and after the first hour the first port was successfully placed into the perineal cavity and we were able to look inside with the scope and see the inside of the perineal cavity and that was very exciting you know never had that view before it's magnified view is very nice and then after another hour all of the ports were in and so I can tell you that at that point I was thinking gosh this seems like bad operation and and so it sort of dragged on and on and you know sort of picking away a tissue and after about four hours I was really honestly hoping that my pager would go off so I would have a reason to leave the operating room I just felt like I couldn't just leave and it would seem like I was you know not sort of honoring the efforts of the attendings that were in the room so anyway five hours the operation was completed successfully the patient did great and that evening my father said so we talked he said so you saw a lap coli how was it and I said of this new innovative procedure it's the stupidest thing I've ever seen definitely don't spend time learning how to do this because it's going nowhere okay now I tell you that story partly because I think it's valuable to reflect on the fact that we don't often know when we're starting out down the road for a new operation if it's actually gonna be a good idea or not we don't necessarily know if it will pan out and so sometimes the early experiences teach us this is a good idea we should keep going sometimes the early experiences teach us that idea we should stop and it also is an example of how good a judge I am of those things which is not good so anyway I'm gonna talk then about this main idea which is that I believe innovation is both the key to surgical progress as well as the greatest challenge in surgical ethics I'm gonna talk a little bit about innovation I want to talk briefly about progress and how we define it and then about surgical ethics so why is surgery today different from a hundred years ago and lots of reasons you know we have antisepsis today we know a lot more about anatomy we wear gloves good things like that all of these things though are examples of innovation and some of the innovations occur sort of in a stepwise fashion sometimes innovation is sort of you know the new idea bright light goes on but the facts of the matter is if we didn't do things differently if we didn't try to innovate we would never change and so it's one of those interesting things about the emphasis on guidelines today right every everywhere in medicine there are guidelines but if we all followed all the guidelines all the time we would always be doing the same things we're doing now and so in fact guidelines are a guide but we have to do things differently and in surgery it is it's interesting that there isn't the same sort of oversight of new techniques as there is for drugs in the FDA and that sort of thing and as Henry Ford said if you always do what you've always done you'll always get what you've always got so we want to do some things differently so I do think it's also important to reflect on differences so in the business world we think about innovation and the innovative leader as someone who is willing to take risks and you know think outside of the box and in surgery innovation is a little bit different because it's not necessarily the surgeon that's taking the risk it's the surgeon putting the patient at risk so if I'm this you know if I'm an innovative surgeon and I think outside of the box that may be great and it may have benefits to me but it's also true that I'm potentially putting my patient at significant risk and so I think that's an important thing we have to think about so risk and patient safety becomes important considerations now as we all know new ideas aren't always good ideas and there's lots of great examples of it and if you want to read an interesting book called bad medicine doctors doing harm since Hippocrates one example there's actually several books today that you can buy about bad ideas and medicine and surgery we won't spend a lot of time on the bad ideas because you know they're kind of fun but not that helpful I don't think I think one important question that we're going to have to address is how do we decide if an innovation is in fact an advance or not and there are lots of examples that we could use and these are some innovative techniques laparoscopic techniques I mentioned you know now we do laparoscopic everything not just laparoscopic colostectomies there are robotic operations there's endoscopic surgery there's endovascular approaches all kinds of cool and interesting innovative things but because I know about thyroid surgery I'm going to just use this historical example and talk a little bit about the history of thyroid surgery very briefly I promise it'll be brief just to allow us to reflect then on some of the specific issues that may come up with new innovation so this goodness it didn't show but anyway there is a there's supposed to be a really nice photo here imagine the gross clinic by Thomas Eakins it's a famous portrait of Philadelphia I'm not sure why it's not showing up but anyway in it is Samuel Gross Samuel Gross was a very famous surgeon who wrote a textbook of surgery in 1866 in which he said about thyroidectomy thus whether we view this operation in relation to the difficulties which must necessarily tend to execution is equally deserving of rebuke and condemnation no honest and sensible surgeon it seems to me would ever engage in it now clearly things have changed at least a little bit because there are in fact some of you in the room today who have been with me in the operating room during a thyroidectomy and it's not that bad you know we we it is sort of you know it's not condemnation time it's it actually is much safer than in the days of Dr. Gross and so I think it's valuable to see things have changed from the 1860s and today in fact there are many innovative approaches to thyroid activity and and I'm gonna go through these very rapidly just again for the sake of discussion because I want you to get a sense of what the options are these are really ways to alter the size or the location of a scar and so so this is an early approach using a smaller incision also in the neck using a scope it's known as the me that or minimally invasive video-assisted thyroidectomy palomically a surgeon Pisa came up with this idea it's very nice it works well some people said yeah but then you still have a scar on your neck so what about making incision the axilla and so this was a Japanese approach going through the axilla with scopes to get to the neck this another group in Japan said well you know rather than go through the axilla when you go through the chest wall it's effective and then people thought well why not put the two together so this is the Baba or bilateral axilla breast approach and so this is another way you can take out the thyroid now as you may imagine this really hasn't taken off in the US and so so so it's you know it's as some would say it's a long run for a short slide and so so you've got to go a long ways just to get to the thyroid rather than just make a small incision the neck but that being said it is an approach and it is can be effectively done now what about robotic surgery today if you can do it with a robot that's always better right because you know robots are really high-tech and you know we advertise that we have them or we have to or whatever we have so this is a technique robotic-assisted axillary thyroid ectomy so it is going through the axilla make a tunnel up to the neck using the robot you know multiple degrees of freedom all that good stuff and it is effective and I personally tried it I don't think it's a good operation I don't offer it anymore but I think you know it can be done yeah well what about notes thyroid ectomy now for those of you who aren't surgery you may not be familiar with notes so notes is natural orifice trans endoscopic surgery so no surgery is like taking the gall bladder out through the stomach so you put a scope down the you know through the mouth down the esophagus into the stomach you go through the stomach grab the gall bladder take it out and then pull it back out so there's no visible scar so you can take out the appendix through the vagina or you could take out the appendix through the rectum or lots of different ways but the whole idea is no visible scar so notes thyroid ectomy and so so this slide when I would give grand rounds in surgery would engender a lot of laughter and all the surgeons say yes that's a great joke notes thyroid ectomy but in fact you can do it you can go through the floor of the mouth and dissects directly down to get to the thyroid and there are a number of techniques that have been done there are some issues with infection things like that but it can be done and so if you think if this looks to you like wow that's a great technique imagine if you added the robot how much better anyway that's just to give you some sense now we you know step back from these various techniques and ask the question are these approaches progress and how do we know let's look at the morbidity is the morbidity are the are the complications the risk of complications from the procedures low absolutely not they're higher is there a change in mortality no the risk of dying from a thyroid ectomy is exceedingly low and there's no change in mortality so what's the difference what's a cosmetic difference and so many people say well is a cosmetic difference a big enough difference to warrant doing all these things and I would say hard to say so how do we decide then if these approaches or other approaches surgical innovative approaches how do we decide if they are progress or not and I would say it depends on what we value if we value not having a scar visible in the neck then these may be seen as progress and if not then maybe not but I would say if then the decision of whether something is progress depends on what we value then it's inherently an ethical question and so we really do need to attend to that so let me then think with you or if you don't mind think with me a little bit about the ethical challenge in surgical innovation using this example of thyroid surgery which I you know I just took you through a rapid historical tour so let's think that about informed consent how can truly informed consent be obtained for something that's innovative well when we obtain informed consent as a surgeon I'm supposed to discuss the risk benefits and alternatives with my patient but if it's really a new procedure I don't really know exactly what the risks are and even if I've done a procedure let's say 50 times if the risk of a complication is only 1 to 2 percent I won't know if that risk is doubled unless I've done thousands of patients so I can't really know what the risks are and so how can I disclose the risks that are unknown it's the unknown unknowns hard to say so as Mark Twain said it ain't what you don't know that gets you in trouble it's what you know for sure that just ain't so and sometimes that's the case with innovative procedures I would suggest that there's another issue and that is how about ensuring patient safety we all know that there's a thing called the learning curve we know that early in one's experience with any procedure we'll talk about surgery we're not as good we get better with time now I can tell you after I had done 20 thyroid ectomies during the course of my residency in surgery I thought I was really good and then I probably did another couple hundred during my fellowship and I thought well now I'm really something and then when I became an attending I got a lot more experience and after doing 500 I thought well now I think I'm as good as I'll ever get and now after a few thousand I think I'm actually better than when I had done 500 now so at some point the learning curve you know levels off and where you are in the learning curve you never really know but it is true that early in one's experience we're not as good and so the question that is how do we disclose that to patients because everything innovative by definition we're early in the learning curve because we don't have a lot of experience with it and so how does that go into the calculations of the patient thinking about the risks how do we disclose those things should we disclose those things so I can tell you that if I was a patient and a surgeon said to me I'm recommending this operation that I've never done before but I think it would work out really well for you I would be running out of that room as fast as I could I can tell you when I said to a patient first time I did a video assisted thyroidectomy well I'm recommending this operation that it's a little bit different and you know I have I've never done it in a live patient before and my assumption was of course this patient's gonna say well forget it you know I'll go see someone else the patient said really you've never done it before I said no you'll be the first one she's like that is so awesome now you can't predict but I think giving patients the information to allow them to make the decision becomes critical well let me focus on just one more thing because I really have to end can surgeons and patients objectively assess the benefits of new procedures so the problem is that something is touted as a new procedure it's new and improved patients read about it on the internet and then they assume that it's better because it says so on the internet and then they come to see a surgeon and a surgeon let's assume that I'm the surgeon I've learned this new technique robotic assisted axillary thyroidectomy I did the training I did cadaver labs I went to other institutions to watch people do it I spent time money in effort to learn how to do it and now I'm waiting for my first patient now my patient comes in saying I read about on the internet I understand it's the best approach ever and literally this happened patient came from Wisconsin said Dr. Angeles I'm so excited I read that you can do this operation I really want it and she was excited and I was excited everyone was excited the only problem was she didn't actually need a thyroid active so so now of course you know I didn't operate on her but but even though I really wanted to but but I point this out not that there's anything inherently wrong with this interaction but the dynamic changes when a patient is convinced that something is the best operation as opposed to yeah you know I know I don't really want my thyroid out but I you say I have thyroid cancer so I need it out so I do think it changes the dynamic and we need to be aware of it and ultimately the question that I started with how do we know when to jump on the bandwagon we don't really know there's not a signpost that says this is a good idea you should do this so I'm going to end with just a few very final comments how can the ethical issues and surgical innovation be managed I would say the ethical behavior of surgeons has to be encouraged and enhanced by thoughtful self-awareness I think that's the first step I think it form consent has to be improved by clearly defining the uncertainties of innovation and surgeons have to gather data to determine if patients truly benefit from these surgical innovations I think that as I mentioned there is no FDA for surgical procedures and so there isn't someone else that decides whether new innovative techniques benefit our patients and so I would say the ethical practice of surgeons is necessary to ensure that what is new is not automatically assumed to be improved and surgeons have to make individual decisions about what to offer patients and so ultimately that becomes then an ethical an ethically charged situation so my conclusions not out innovative techniques are good clearly potential benefits need to be weighed against risks surgeons need to actively engage in clinical trials or registries in order to assess risks and benefits informed consent has to address the uncertainties that has to be clearly disclosed and we need to ensure that all surgical innovation benefits patients and not just us because if I've come up with a new technique and it's on the internet I'm gonna get a lot of patients that's gonna be good for me whether it's good for patients or not is open for discussion and I would suggest that this idea it should be good for patients and not just for surgeons is really the epitome of ethical practice which is why I started with this idea that I think innovation is both the key to future surgical progress as well as the greatest challenge in surgical ethics so thank you very much for your attention than the former now I know we and we all know surgery has different criteria you don't go through the FDA for procedures I'll grant you because it's certainly part of your talk that innovative practices have certainly improved surgery for patients and not just just for doctors it seems to me that can also be said though of experimental treatments so say something about what you see as a potential distinction if there is one between the two terms yes no excellent point Mary so so I guess I would say I mean first of all I think our assumption is that innovation is good that something that is new is always better that's our assumption it's not a correct assumption and it's not the assumption of medicine but it's the assumption of the American public which is why we all have to buy the next iPhone right my my old iPhone still dials it works but I have to buy the new one because it's new and improved it does something more so so I do think that the using innovation innovative technique automatically suggests that it's better and we don't know that it necessarily is it's different the second point though that you make is an excellent one and that is that I think experimentation so experimental surgery I think suggests that it is in a research context and so I would say early on we should push innovative procedures into a research context but frequently they don't start there and so that's the other thing that I think it's challenging so often innovation occurs without research oversight without IRBs but the more rapidly it's pushed into the research arena to become experimental the more rapidly we'll gather data to know actually if it's better or not thanks Rachel so as we think about moving away from fee for service to pay for performance does the monetary impact of your innovations come into play now more than it did before it's an excellent question I believe that the answer is going to be yes although it's a little hard to know how it's going to play out so so I do think that if we try things out and it's if we know that we there are more financial penalties associated with things that don't work as well I do think that that is going to reduce the likelihood of sort of doing things very differently I think it's going to mean that frequently changes happen in a more stepwise fashion and not so much as sort of the big new idea but rather much more incrementally because I do think the financial ramifications of choosing wrong on that you know is this a good idea or not should we invest in it or not I think that there's going to be a lot more conservatism thanks last question thank you a little bit of an aside but you talked about learning curves being better after several thousand concurrent surgery has been in the news of late any thoughts about that you know it's an excellent point and I would love to spend time talking about it but one of the speakers in a short time on this panel Dr. Alex Langerman will be addressing that very topic so