 Ladies and gentlemen, today is the last professionalism seminar of the winter quarter, and we will start again with Richard Epstein from the Law School on March 28, the first Wednesday of the new quarter, and Richard will give a provocative talk on deprofessionalization of medicine. Who would have imagined anything else? But today, today we're delighted to welcome the newest endowed professor at the University of Chicago, Peter Angelos, who on Monday was officially appointed the Linda Kohler Anderson Professor of Surgery and Surgical Ethics by Dean Polanski. Peter, as you know, is a distinguished endocrine surgeon who belongs to all of the right endocrine societies and surgical societies. I think, I think he, he told me, I'm a good surgeon too. Yes. Today, today, for example, he, he and Karen were working on an extra adrenal pheochromocytoma, which I, Karen was really impressed. I remembered extra adrenal goes to the organ of Zuckerkandel. Did I get that one right yet? And, and, and that, that's one of those moments when both Karen and, and Peter said, you don't want it to get exciting. That is, you don't want the blood pressures to spike, but, but they often do anyway when you touch the tumor. And Peter is also regarded as the national leader in this new field of surgical ethics, a member of the American College of Surgeons Ethics Committee, the chair of the American Surgical Oncology Groups Ethics Committee, and, and other groups. Peter also, some of you may know, won the Peer Recognition Award this year. Shalini, what's, what's a, what's a fancy title for the, oh dear, I know, if you won the Peer Recognition Award. I apologize. It always happens to me at the restaurant, the waiter says, is everything okay? Everything is okay. The Peer Role Model Award, selected by all of the faculty at, at the medical center. And that's a great honor. Today, Peter is going to talk to us about living and teaching professionalism, a surgeon's perspective. Peter. Mark, thank you all very much. It's a, it's a pleasure, of course, to be here. And for some of you who may have heard me speak several times in the last couple of weeks, I apologize. And I have a disclosure to make, and because you know when you start every academic talk, you have to give the appropriate disclosures. So my disclosure is that Mark actually asked me for the title for this talk way back when he was printing this nice brochure. And I had absolutely no clue what I was going to talk about. And so I was trying to come up with a good generic title that would fit in the series. And I thought I came up with a pretty good one. So that's my title. Unfortunately, that is not my talk. So, so my talk is actually technology and innovation in surgery. Are we honest with our patients? And I will try to explain to you why I think that this is a very relevant talk for professionalism. But anyway, it's not as advertised. So, so of course, in during the course of this series, those of you who have been here have heard multiple people talk about lots of different ways to look at professionalism and define it and all sorts of things. And so for those of you who may have missed one or two of the talks, I'm going to just mention from Merriam-Webster's Collegiate Dictionary, the definition of professionalism is the conduct aims and qualities that characterize or mark a profession or a professional person. Now in terms of a sort of providing a goal to shoot for, it seemed to me that that's pretty bland, pretty dry, and not very helpful. And so, and I do think about professionalism very much in an aspirational manner as something that we should aim for, acting as professionals, etc. So let me give you a different, well, before I do that, of course, you know, I reviewed some of the literature. So, so in the last few years, lots of great books on professionalism in medicine. This is the one Richard and Sylvia Cruz who were here earlier, David Stern, talking about measuring medical professionalism. I'm sorry, Karen, would you mind answering that? And just say, I think the answer is yes to that question. It was just a calcium level, it's okay. So there have been many, many recent attempts at defining professionalism and books written about it. And so in an effort to kind of start with a baseline, I looked, of course, to the most essential definitions of professionalism, which are in the surgical literature. And this, in fact, unfortunately Karen just stepped out. And this is from the Canadian Journal of Surgery, no less. The basics of professionals, I would say, are nicely put forward here in return for professional autonomy, self-regulation, and a recognition of their unique place in society, the public demands of physicians, accountability, ethical standards, and an altruistic manner of delivering care. So I thought that that was very nicely put. The things I really would like you to just, in particular notice, the concepts of self-regulation, altruism, and ethical standards. And so for Karen, it's from the Canadian Journal of Surgery. So I think that this is going to be kind of my starting point. And I want to just mention a little bit about innovation in surgery. Again, some of you have heard me talk about this in the past. I think it's a really important issue for surgery and how surgeons interact with their patients. I want to talk a little bit about the lore of innovation as well as this issue of assessing innovation and how do we know if innovation results in something that's good for patients. And because I'm an endocrine surgeon, I'm going to use the example of thyroid surgery. I'm going to use this as a concrete example of what I believe is the importance of professionalism because I like the theoretical discussions. They are a lot of fun. But for me, it has to have some relevance in how we take care of patients. And I think there is a direct correlation. So in terms of technology and innovation in surgery, there's no question that innovation may lead to new technology. And similarly, new technology can be used in different innovative ways by surgeons. Frequently innovation is just having a different idea, thinking about a different way of doing things. There's another issue which is how do we disseminate the new techniques or a new approach outside of the center where it was developed. That's a whole other issue in surgery which I think is an important ethical issue, but we won't be talking about that today. So I would argue that innovation is absolutely critical to the success of surgery. And much of that innovation occurs by people trying things out. And just to give you a sense of sort of this notion that innovation is important, let me ask you to consider what it would be like going into an operating room in perhaps 1950 for colisosectomy, removal of a gallbladder. Now I wasn't in practice in 1950, but it would look something like this. This is a historical photo and I'll just point out a couple of things for you. First of all, I think it's important to note that everyone in the OR that we see here is a man. I want you to notice the gowns, they're all cloth gowns, cloth masks, cloth hats. Notice the lighting. Now we don't really see, I'm guessing that this guy is the anesthesiologist because he doesn't have gloves on. That's what I'm guessing. And what you'll notice though is that there aren't a lot of monitors up there. I'm sure he's watching the patient breathing. But we've got the lights, just sort of notice the instruments. Everybody's focused on the patient. Now this is a representative of a laparoscopic colisosectomy today. Lots of differences, okay? First of all, it looks like the primary surgeon is a woman. That's an important thing, an important difference. The anesthesiologist, interesting. Everyone is actually looking at the monitor, including the anesthesiologist. Now I'm not sure what that says other than he's paying close attention to the field, which is important. But it is interesting now that this is a laparoscopic operation. So our instruments are very different. They're completely different from the instruments you saw before. And nobody's actually looking at the patient. They're all looking at the image because that's how we operate laparoscopically. Again, so a very big change. In the background here, you can see the monitors. They're very different that the anesthesiologists are using. So I would say there's a lot of new technology. There's a lot of differences. And I would say these have been good. These are better now for patients in this context. Now, not only though, is innovation good for patients, but it's really great for surgeons. There's no question that innovation is great for marketing. It really sells. Everything you'll notice is new and improved. Because it's not enough to be just improved, it has to be new and improved. Interestingly enough, there's a tremendous value for all hospitals being innovative, but especially for surgery. Surgeons want to be innovative. And I would say, if you look, I did some high-level research. So I went to our website, the University of Chicago, which is of course at the forefront of medicine, very innovative there. And I looked up our departmental website. I'm quoting, the University of Surgeon is one of the most innovative, multifaceted surgery departments in the nation, featuring leading edge, whatever. But we're innovative, we're leading edge, we're right out in front. And that is, I would say, that's a good thing. That's where we want to be, but it's also great for marketing. And I think we can't overestimate the power of the words that we use and how it has implications for patients. Innovation is assumed to be good. And there's no question that if you ask patients, well, you can have your operation at this hospital where they do the tried and true, or you can go have it at the hospital where they use innovative techniques, patients will say, well, of course I want the innovative techniques. In addition, so they want the innovative surgeons. Now what does surgeons want? Well, surgeons also want the latest technology. They want to be doing cutting-edge stuff. And that's one of the reasons why we have things that work, but we want something a little better. And it's not just surgeons. Actually, I would say all of America is so focused on this. Why is the new iPad selling out? Doesn't everyone have an old one? Why is it that you need an iPhone that you can talk to? Why does that seem so valuable to us? Well, it's new, and it's different. It's kind of exciting. And I would say there's something along the same lines in how patients and surgeons interact. There's no question everybody wants this latest and greatest, and that's what I've pointed out. Now, I would say, though, it remains difficult to know when an innovation is actually an improvement for patients. And the reason is that how we think about progress in surgery, I would argue, has changed. So let me tell you the traditional criteria of surgical progress. And this is defined by reductions in morbidity and mortality. Morbidity and mortality goes down. We say that's good for patients. Everybody's happy. These are things that can be objectively determined. We can gather data on it. We can have P values in tables, and we can present papers on it. It's very scientific. We can measure it. And that's an important thing, to objectively define improvement. Let me just give you a case as an example. And some of you have heard this case recently, so I apologize. Again, I don't only have so many original thoughts, and in a few short weeks, I can't do that much. But anyway, so here's the case. This is in June, let's assume. June 1972, a 70-year-old woman came to the emergency room of Champlain Valley Hospital in Plattsburgh, New York. Now, you may say to yourself, why would anyone go to Champlain Valley Hospital in Plattsburgh, New York? Well, that's where my father was a general surgeon. So my father would have seen a patient like this. So if she came in after a week of intermittent recurrent left lower quadrant pain, fevers, and an elevated white blood cell count, she would be managed in a particular way. Now, I just want to remind you, this is 40 years ago, in case you're having trouble with the math. It's a long time ago. So once a diagnosis of a diverticular abscess was made, the surgeon would recommend a three-step procedure for treatment. And again, many of you may not be familiar with how we used to do this. And again, I'm saying we. I wasn't practicing surgery then, but I know. I read the books. Open the abdomen, establish a diagnosis, and perform a diverting colostom over a rod. That was step one. Step two, after antibiotics and a bowel prep, we would resect the diseased bowel and do a primary anastomosis. This is second operation. Second operation. Right. Yes, good point. So far, two operations. But the patient still has a colostomy. So then the third operation was close the colostomy. So three operations. This was very safe. People did very well. This was considered standard of care. Nobody said, oh, gosh, why did you put patients through with three operations? Said, this is how we do it, and patients do well. And patients will go back to their surgeons to say, thank you so much, you saved my life. What do we do today? Well, if I'm on call, patient comes into the emergency room with a diverticular abscess. First of all, they're kind of unlucky, because I'm on call. And I'm an endocrine surgeon, but that's OK. So let's assume a diagnosis of diverticular abscess is made. What do we do? Well, we do percutaneous drainage. We call the radiologists. We do a nonoperative management. Things cool down. We treat the patient. Everything's good. And then we do an elective colomor section with a primary anestimosis. One operation. Now, I would say most everybody would agree this is good for patients. There's been a significant reduction of morbidity and mortality. And I would argue that this is an improvement in patient care that occurred as a result of a series of innovations. It wasn't any new device. It wasn't any new technology. This was just surgeons trying something out, doing something differently. And over time, we've significantly changed how we manage things. So I would argue this is a situation in which innovation is clearly good for patients. Now, unfortunately, if you look at the history of surgery, not all innovations have actually been good. And so let me just give you a few examples of those that aren't so good. So transplanting goat testicles into humans. Again, some of you aren't familiar with this. I would recommend the book, Charlotton by Pope Brock. It explains the doctor in Missouri, who around the turn of the century decided that he could treat impotence by transplanting goat testicles into men now. And then he realized, you didn't actually need the whole testicle, just a piece of a testicle. And it didn't actually work just for impotence, but it worked for aging and being tired. And then it expanded. Women were getting it. And this guy was actually the busiest, most the richest surgeon in America. Now, in case you're wondering, how is it that we don't do this anymore? Right? But the reason is it doesn't work. So that's the problem. So this was something that thousands and thousands of patients had this surgical procedure done, but it doesn't work. So some other examples. Gallstone lithotripsy. Now, this may have completely passed you guys by. But when I was a surgical resident, this was the rage, gallstone lithotripsy. And some of my colleagues spent two years in the basic science lab working on gallstone lithotripsy. And this actually, this is from about 1992. And this is the latest device. We actually, I was a resident Northwestern. We got one of these really expensive German devices. And they renovated a whole room for it. And my friends, the residents who were in the lab, were so excited. We got the greatest lithotripsy device. Now, again, how come we don't do this anymore? Well, it doesn't work. All the patients, you could break up the gallstones, but they all come back. Well, we figured out you can treat them with a medication, but they have to be on it for the rest of their lives. So that didn't seem so good. All of a sudden, laparoscopic colisosectomy came around, and people said, well, why would I want to be on medication for the rest of my life? Just take out my gallbladder and send me home the same day. So again, this was thought to be a great innovation. It didn't really pan out. One more, this is prefrontal lobotomy. So this was done in many, many patients for the treatment of schizophrenia, for the treatment of depression, lots of things, prefrontal lobotomy, very good. And lest you think, well, those were a bunch of quacks that didn't really know, the guy who came up with this was the co-winner of the Nobel Prize in Physiology and Medicine. So this was well-established. By around the early 1950s, 20,000 patients in the US had been treated this way. Now again, we don't do it anymore. Well, why not? Well, it doesn't really work. So the question then is, how do we decide if an innovation is actually in advance? How do we know if it's actually going to be good for patients? So we look back on these things and we say, well, of course, that was really stupid. But at the time, it's sometimes hard to say. So let me, again, talk about something that I know something about, because I don't know anything about colons. Well, a little, but not that much. But let me talk about thyroid surgery. So this is a famous portrait, the gross clinic by Eacons. It's in Philadelphia. And this surgeon here, now again, this is a long time ago. So a couple of things that are really interesting to note. We're in the operating theater, all right? And this is actually supposed to be a self-portrait of Eacons, just for those of you who are in art history buffs. This person is shielding their face. But the surgeon who's wielding the scalpel, no mask, no white coat, no gloves, this is the person delivering anesthesia, which in those days was a lot of what we call OK anesthesia, saying, OK, OK, OK, and holding the patient down. Now it's a little bit different from today. But anyway, so Eacons, I'm sorry, so gross, his portrait is so often seen in surgical textbooks because he was a very influential surgeon. And this is what he said about thyroid surgery. This is from his textbook in 1866. Thus, whether we view this operation in relation to the difficulties which must necessarily attend its execution or with reference to the severity of the subsequent inflammation needs is equally deserving of rebuke and condemnation. No honest and sensible surgeon, it seems to me, would ever engage in it. And then if you weren't really sure how he felt, he went on to say, can a gland, when in a state of enlargement, be removed with the reasonable hope of saving the patient's experience emphatically answers no if a surgeon should be so adventurous or foolhardy as to undertake the enterprise, I shall not envy him. Every stroke of the knife will be followed by a torrent of blood. And lucky will it be for him if his victim live long enough to enable him to finish his horrid butchery. Now, a couple things to reflect on. Certainly, we don't see this kind of writing in the surgical literature today. So if you pick up any surgical journal, you see p-values. We see a graph of slightly differences in outcomes. But we don't see this kind of writing. Well, why not? Partly, it's because things aren't this bad. Now, there are only a few of you in the room who have been in the operating with me in a thyroid ectomy. But it's not that bad. And we don't even use cell saver for thyroid ectomy. For those of you who are in surgery, you know that's a joke because we lose about a teaspoon of blood. So things have changed. Well, what changed? Well, I would say a few things changed. For one, Koker, this is a theater Koker. He was actually the first surgeon to win the Nobel Prize in surgery. And his techniques in thyroid surgery allowed the mortality of treatment for thyroid ectomy to drop from 12.8% in his first series down to 0.5% in later series. A huge reduction in mortality. And I would say by the 1920s, most principles of safe thyroid surgery had been well-established. And in recent decades, the discussions in the context of thyroid surgery have largely been about minimally invasive thyroid ectomy. And this has led to a number of innovative approaches to thyroid ectomy. So let me just give you a couple examples again. Yes? Just one quick question. Yes. Did the two overlap? Gross was in Europe. Koker was in Europe. Yeah, Koker was in Europe. Gross was here. I would say Gross was probably pretty much done his career by the time Koker was. But was he alive to see that? To see that? I don't know. Yeah, that I don't know. Great question. Yeah, great question. There's a book to be written about that. All right, someone make a note. So let me talk to you a little bit about minimally invasive thyroid surgery. And I'll just go over this quickly because this is great stuff for me. But I know it may not be for you. So I'll go through it rapidly. So there's different ways to handle the approaches of scars. So one way is to make the incision very, very small. And I'll show you a couple of different ways to do that. The other is to move the incision away from the neck. So it's not as easy to see. So even if you have a big incision, if you can't see it, not so bad. And I'll just mention all these very rapidly. So this was an endoscopic approach. And I apologize. It doesn't project very well. But this is from a Japanese article. The patient's head is up here, feet are down here. And there's a number of devices to lift the skin and the platysma. And then an incision is made here. And there's a grasper coming in here and an endoscope there. And so this was a way to do a thyroidectomy without an incision in the neck. And it's effective. Took a while. But I have to say, when I looked at this, I thought, lots of hardware kind of seemed like an orthopedic procedure. I didn't think I could do it. So now this was a different approach. So this was called the video-assisted approach. And this was by a professor, Mikali, in PISA. And so this approach is incisions in the same place. And we actually use scopes and long instruments. And we just do everything through a 2 and 1 half centimeter incision. And the benefit is you use a camera to see things that you couldn't see with the naked eye. And I think this is kind of a nice approach for select patients. But you still have a small incision in the neck. Now, what about moving incisions away from the neck? Well, a couple of ways to do that. This was an axillary approach. This was from Japan. And again, patients head here, feet are down here. And the idea was the patient's arm was placed above their head. So that shortens the distance between the axilla and the thyroid. And so this was done with scopes and long instruments and very effective. Took a while. Dr. Akeda, who's the person who came up with this, would do an excellent thyroidectomy in four hours, a lobectomy. That's kind of long for a lobectomy. This was yet another approach. So this was the idea of making the incision down near the xiphoid or in multiple places and tunneling up. And again, the idea is no incision in the neck. There are still incisions. And then people said, well, we'll put it all together. We'll do the breast approach and the axillary approach. And so this is the BABA bilateral axillobrest approach. And I have to say, so multiple incisions working here on the thyroid. And this can be done. It's very effective. So this is from a study, 103 endoscopic thyroid ectomies with 198 conventional thyroid ectomies, very similar outcomes. Patients were very happy with the cosmetic results. And I have to say, when I read this, and I thought, well, gosh, if I have a young woman who has a 1.5 centimeter thyroid nodule, and I say, I can make incisions in both your breasts and both your axilla and take out your thyroid, they're going to say, let me out of here. Where can I find another surgeon? And so this, I would say, has really not taken off at all in the US. Just really, I don't know anyone in the US that has done this. It's been done in the Far East, some in New Zealand, Australia. So well, then the Koreans came up with this idea. That actually has gained some traction in the US. And this is robotic-assisted axillary thyroid ectomy. So they thought, we'll take the axillary approach, but we'll add a robot. Because what could be better than adding a robot? Because that's more technology. And pretty much everybody loves the idea of robotic. Now, I'm not sure why that is. I'm not sure if patients feel comforted knowing that there's a robot involved. I'm not sure. But in case if you don't, this operation is done with a 5 or 6 centimeter incision in the axilla. And then everything is lifted up. And everything comes in through the axilla. And the reason that you use the robot is it has these instruments that are risted so you can do everything in a small space. And this approach has gained some attention in the US not a lot. But I have found that most of my patients who I discuss this with say, why would I want that? But yet another approach. So if you all have heard of notes surgery, notes is natural orifice, transendoscopic surgery. So notes is things like going in through the stomach, like an endoscope into the stomach, opening the stomach wall, taking out the gallbladder, and then pulling it out through the stomach. And this has been done lots of places. Or you can do a transvaginal appendectomy. So no incisions on the skin. The incisions are inside. So let me just take a moment because I just thought it was so cute. When I first told my daughter, my youngest, Audrey, when Audrey was about eight years old, my colleagues at Northwestern had done a lot of work on this. And there was the report that they had done the first notes colisostectomy in Chicago. And so I try, as much as I can as a surgeon, I can't bring my work home. But I try to talk to my kids so they know what I do. And so I was explaining it. And I said, so this is what they did just as I explained to you. And my daughter said, you mean to tell me that they went through her stomach and then they took out her gallbladder and then they pulled it out through her mouth? I said, yes. And she said, didn't that leave a really bad aftertaste? Which is kind of how I think about note surgery. But anyway, that's an aside. So somebody said, well, if you can take a gallbladder out through the mouth, the thyroid's a lot closer. Let's do note thyroidectomy. And there is, in fact, this approach through the floor of the mouth. And you add the robot. So it's kind of like you got everything. Now, there's been a small series, maybe a dozen patients from Germany reported utilizing this approach. Actually, I don't think they used the robot because they said, well, what do we need a robot for? But anyway, the results aren't great. And again, I don't think it's going to take off, especially in the US. But it can be done. So this is the question. Are these approaches progress? And how do we know? How do we decide? I would argue there's little change in morbidity. If anything, patients have more pain than a small neck incision. If you make an incision in the axilla and tunnel all the way up to the neck, that's a lot of dissecting. If you have to do it on both sides, it's twice as much. Patients tend to have more pain, but they all recover very well, nevertheless. There's clearly no change in mortality. The mortality from thyroidectomy is so vanishingly low that you're never going to show that you can improve that. But certainly, it's no worse utilizing these techniques. The only difference is a cosmetic difference. So you don't have an incision in the neck. Now, despite what you see, if you Google images, thyroidectomy, you'll see several hundred patients that post their thyroidectomy scars on the internet. Now, most of them don't look that good. But I would argue that the people who have a thyroidectomy and their scar looks good, they don't post their images on the internet. I would also argue that it would suggest that people have way too much time on their hands. But that's, again, another story. So the question is whether only a cosmetic difference is any less important than other differences? And again, how do we assess that? Do you have any metrics on the cost differences? Well, it's very hard to assess. Certainly, in the US today, it is more expensive. And I'll come back to this in a minute, though. So let's look at a couple things in terms of how do we decide if the innovative technique or technology is in advance. Well, we look at efficacy, the ability to produce the desired effect in expert hands. And then we also look at effectiveness, which is the ability to produce the desired effect in normal usage. So if there's one guy in Korea who can do a robotic-assisted axillary thyroidectomy, and it takes him one hour, and it doesn't take any longer, he's really fast, and everything is great, that would show that it's efficacious. But the question is whether the rest of us can do it, that would be the question of effectiveness. And sometimes, that's where problems occur. Now, I would argue that these two categories do not really help us in answering this question. Because I would say that in order to decide if something is progress, we have to look at what is it that we value, because it's that decision of what we value that helps us know whether it's better or not better. And that, I would say, can't be measured purely objectively. So let's look a little bit more carefully at the ethical issues in surgical innovation. So I would say if you take a new operation, you don't really know what the risks are at the first time you do it. So you've tried it out, you've done it in a cadaver, maybe you did it in a pig, maybe you did it in 10 pigs. They all did well. But at some point, you're going to operate on a patient, and you don't really know what the risks are. With thyroid surgery, we know that there's a 1% to 2% risk of complications. And those complications are hoarseness or low calcium. In order to show a change in something that is a 1% or 2% risk, you have to do thousands of an operation because it's such a low risk. And so as a result, you can start out and say, we don't think there's any additional risk. But you'd actually have to keep saying, we don't know. We don't know until you've done thousands to be able to assess the risks. So I think that that's a problem because early on, patients want to know what the risks are, and surgeons can't really tell them because we don't know. The other issue is, can you really know what the risks are when you first start out? The first few times you do something, there's a little bit of this leap of faith. And that, I would argue, is necessary in order to take a step forward when you don't know exactly where you're going to land. But it's very problematic in terms of explaining risks to patients. So how do we ensure patient safety? Well, we have to address the lack of surgeon experience with a new technique. Now, we all know that there is a learning curve. And in surgery, how steep that learning curve is depends on the operation. But I would argue that I'm better now at doing a thyroidectomy after having done 2,02500. I'm not sure. But I've done a lot. I'm better now than after I had done 50. Now, when you ask me after I had done 50, do you think you do a good operation? I would say yes, I do. I think I do it safe, and I do a good operation. But people get better, and so it's very difficult to know how to talk about the learning curve in general with patients, but especially with a new operation. You can raise the question, should we discuss this with patients? Well, I would argue yes, it's in fact important. But how to do it is not always so easy to define. So again, surgical progress and surgical benefit, I would say has traditionally been defined by reductions in morbidity and mortality, and that's been valuable. But today, I think that we have to think about benefit in a broader category, because patient values become important. And that's where I would say a cosmetic benefit may be beneficial. If a patient's goals are to have the smallest scar or not have a visible scar, then if we can accomplish that, we may have actually done them a service. And figuring that out, I think, is difficult. Now, with respect to this question of patient benefit, well, if you look at the easy example that we talk about much more commonly in ethics, a procedure that may shorten a patient's life but improves their quality of life, certainly nobody would say, well, that's not beneficial because the patient lived a shorter period of time. It just dependent on the patient's goals and values. So I would say in a similar way, we have to think about how do we assess the quality of life and utilize that as one component of determining whether something is surgical advancement. Now, the problem with quality of life is you can't ask a surgeon about the patient's quality of life, because that's something that patients have to determine themselves. We can use lots of tools to help do that in as rigorous a fashion as possible. But ultimately, we have to go to the patient to get that information. So surgical progress. I would argue that there's been a paradigm shift. Whereas we used to look solely at objective criteria, I would say now we have to look beyond that. We can't determine whether something is better looking solely at the objective criteria. And I would argue that if the only benefit is improved patient satisfaction, that that might actually be surgical progress. Now, it isn't necessarily surgical progress, but it might be surgical progress. Finally, to say that something is a purely cosmetic benefit, I think is to inappropriately minimize the importance. For some patients, a purely cosmetic benefit may be of particular significance. And so that may lead to improvements in their quality of life. So let me ask this question, can surgeons and patients really objectively assess the benefits of a new procedure? So just imagine, surgeon, let's assume me, has decided that a new technique, robotic-assisted axillary thyroidectomy, for example, that I've decided this is worthwhile. Other people are doing it. I should probably learn how to do it. Maybe it's actually better. We don't really know. I should study it. We should find out. So I spend time learning the technique. I read about it. I watch videos. I go watch other people do it. I do cadaver labs. It costs money. It costs time. A lot of effort. And at some point, I'm fully trained. I'm ready to do it. So in that circumstance, I want to ask you, can I objectively present the options of this operation to a patient who may already have decided that the high-tech new robotic operation must be better because they read about it on the internet? So I would argue that we're in a situation where the patient may already have in their mind, I want this because it seems so much better. And I, the surgeon, has already invested all this to say, hey, I think I need to learn how to do this. And so I think the dynamic of the doctor-patient relationship in this circumstance with a surgeon who's learned something new and a patient who's convinced, for whatever reasons, that it's better, are going to collide with the patient saying to the surgeon, I don't care what you say. That's what I want. And pardon me. I would argue that's very different from most surgery. Most cases, the patient comes to me and they don't necessarily want to have an operation. They may understand that they need one. They have thyroid cancer. The thyroid has to come out. They may not want it. But they understand, OK, there are risks. The benefit is, I'm not going to have cancer and that's going to be good. And so there's this sort of negotiation. I'm telling them what they need, what the risks are. But I don't generally have patients coming in saying, I so very much want you to take out my thyroid. I've read that having the thyroid out is so great that I want you to take it out. That's not generally the case. But that is sometimes the case with new technology. So costs. So Peter mentioned the issue of costs. There's no question that new technology is usually more costly. And in this case, it's definitely more costly. In addition, we have to spend more time utilizing the new technology. Even if it's not that expensive, it takes us longer because it's different. It's new. And so there's a tendency to say, well, if I can do a thyroid lobectomy in one hour and it takes me four hours to do it with robotic assisted axillary approach, that we could say, well, that's just crazy. Let's not do it. And you could make an argument for that. I would say that one of the problems, though, is that when you try something out the first time, you don't always know what the ultimate benefits are going to be. So again, thinking historically, when I was a resident, one of my faculty members did the first laparoscopic colisostectomy at our hospital. And all of us residents who weren't busy doing something else went to watch. And it took five hours, five hours to do a laparoscopic colisostectomy. Now these days, 30 minutes, right? Piece of cake, nothing to it. Patients go home the same day. And we watched that operation. We all left the OR thinking, this is a bad idea. This is a big mistake. And I remember this particular attending, great guy. He persevered. He got better. He got faster. But still, the old-time general surgeons would say, that's not even really surgery. You're just picking away at the tissue. Give me a real knife and a big incision. A few years later, even the old-timers were learning how to do laparoscopic colisostectomy because it was, in fact, better. It doesn't take five hours all the time. Patients' recovery is much better. Lots of parameters. So if we say no too early, we may not know what the ultimate benefits are. And that is, I think, the problem with cost. This is much more expensive. It takes a lot more time. So then I believe the tension that we are faced with is, should we be encouraging more new technology and innovation to help more patients? Or should we be protecting patients from the unbridled enthusiasm of surgical innovators? Surgeon says, I think it's a great idea. We should do it. And I'm sure the marketing department would love it. But is it actually good for patients? So I have a few concerns. I would say that individual surgeons are faced with the challenge of determining what innovative techniques should be offered to our patients. I think that that's a question that we, as an individual, I, as an individual surgeon, I have to assess that. I have to be able to make recommendations to my patients. I think that when it comes to quality of life, it's hard to assess objectively. But it can be done, but I ultimately have to ask the patient in some fashion. And we can't assess whether we're improving quality of life simply by looking at a patient. We can't look at it and say, wow, your scar looks much better. I've improved your quality of life. It doesn't work that easily. So let me try to bring this back to professionalism, because I'm sure you're thinking, well, this has been interesting, but what does this have to do with professionalism? Well, I would say that there is no group or institution that determines whether a new technology benefits patients. There isn't somebody that says, OK, you can do it. This is good. In fact, I would argue that professionalism of surgeons is necessary in order to ensure that what is new and what we offer our patients isn't automatically assumed to be better. And then finally, I would say with no oversight, it's possible that surgeons can go off the deep end on either side here. We may not want to ever try anything new, or we may want to try everything new. And that's where I think there has to be some very important judgment, and that's where I think that professionalism comes in. It's making an assessment about what is going to ultimately be beneficial for my individual patient. So how can these ethical issues and surgical innovation be managed? Well, I would just argue a couple things. First of all, I don't think that we can legislate this. I don't think that there can be any group that necessarily regulates this. I think that we have to have self-awareness. We have to have surgeons that think about this and are honest with themselves and with their patients. Informed consent has to be improved by explaining very clearly the uncertainties of innovation. So I had a patient who said to me once, I had an innovative operation and I have this complication. And she said, how could that have happened? And I said, well, it seems to me easily could have happened. And she said, well, my surgeon, who did the innovative operation, said that couldn't happen. And I said, well, it's impossible to know if it could or couldn't happen because nobody's done it enough. And then finally, I think surgeons have to gather data to determine if patients really benefit. So if a patient is convinced that something is better and we can figure out that we're not putting them at significantly increased risk, then I think with appropriate consent, it is possible to move forward. But we do need to continuously assess are we actually getting the benefits that we think we're getting? So my final conclusions, I would say not all new technology is good for patients. I think that not all innovation is great. I think that when you're looking at things like quality of life, you have to balance that against potential risks for patients. And I do think that we have to spend a lot more time thinking about informed consent, how to make it better and much more relevant to the actual procedure that's happening. I think that we need to ensure as we go forward that new technology, new innovation actually benefits our patients and not just us. And I think that's to me an absolutely critical aspect of professionalism and that is, is something really going to benefit my patients? And sort of having the thoughtful context in which to make that determination. So I thank you very much for your attention. I'd be happy to answer any questions. Jolly. One to consider is that, is the learning curve and the number of procedures that someone has done? You can say that not all innovation is good for patients, but you also have to throw in not all innovations done by every surgeon is good for patients because that learning curve is just so, such an important component. No, you're absolutely right. And again, I would say that to me is another excellent example of where we have to depend on the professionalism of an individual surgeon to say, even though Dr. Chung in Korea can do this operation with great results and in fact has done it for thyroid cancer, I shouldn't be offering that to my patients. I don't have the experience. And that's where I do think that we have a problem today. I think that it's too easy to say, so and so has done it. They've written a paper about it. It's in the literature. It's no longer, it's not innovative. And again, I think you're absolutely right. What is innovative for the expert and it's low risk for the expert may not be the same way for every surgeon. Excellent point. I think you're right that at a minimum, whatever system develops, you need to push the professionalism in terms of the individual doctor's decisions. But the house of surgery and the house of medicine historically has never been able to do it in terms of you look at the ultimate decisions, then as you mentioned, some of it may be well-intentioned in terms of people believing that the new technology is better or the patients push for it, but the economics are just so powerful in terms of both the individual physician as well as the University of Chicago in terms of an organization pushing. So therefore you see these policy things being developed, so for example, value-based insurance or you see like the New York Times talking about that tutorials where the patients paid the extra beyond what's been proven to be beneficial or in the Affordable Care Act, there's provision for that vision board separate from Congress to talk about what it may be paid for or not. So do you really sort of see a solution that really relies solely upon physicians as in your last slide or do you think that based upon the history of the past 40, 50 years that you gotta have sort of systems, legal, regulatory solutions as part of it? Yeah, it's a really excellent point that the history has not been particularly a shining example of great self-regulation. I think that's absolutely true. So I fundamentally am not in favor of lots more regulation. On the other hand, I think that there has to be some level of oversight and I think that it may be something like, I mean maybe there does need to be different tiers of things and so maybe if you want the transoral robotic thyroidectomy, maybe that should be something that you pay additional for as a way of sort of reminding the patient that what you're doing is really outside of the mainstream and to me, I mean that may be a good approach where we're not saying you can't get it and we're not necessarily saying innovation should not occur but what we're saying is patients need to know that they're really stepping outside of the mainstream and when there's significant costs associated with that then perhaps they need to bear those costs. So I would say I think as much as I hate to admit, I think some regulation or some legal approach is gonna be necessary. Just to follow up on Marshall's question. Using the concept of professionalism, could you extend it from individual surgeon's decisions to sort of the community of surgeons which might go halfway towards a regulatory approach? It wouldn't get all the way to Marshall's idea. Yes, so no, I think that that's a very good idea and there has been an attempt to do this sort of thing and so there was a task force of the Society for University Surgeons that looked at this issue and tried to make some suggestions and one of their suggestions was to have surgical innovation committees at individual hospitals to sort of provide oversight and they sort of looked at this as an alternative to an IRB as a way of surgeons kind of policing themselves. I think that the problem is that there really hasn't been, if you say to an innovative surgeon like Larry Gottlieb, hey Larry, before you do something different, come and tell us what you're gonna do and we're gonna approve it. It doesn't necessarily go over that well and so I think that there is a way to do it but I don't think we've necessarily come up with it yet. So I have a question that's somewhat similar. Innovation is very easy to recognize when you bring in a huge robotic arm and you invest thousands of dollars but sometimes innovation is more subtle than that. A surgeon goes into the operating room and decides to do something differently than he or she has done before. How do you do surgeons think about this ethical boundary between common accepted standard of care and innovation and who regulates, is there any regulation when a patient signs a release? Are they saying you can do anything you want inside that two centimeter scar? You've promised me. Yeah, so it's a great question. In fact, yes, patients do, patients say I'm giving you permission to do a thyroidectomy and anything else you would deem necessary during the course of my operation. So in fact, and we've talked about this, some of you have heard me talk about this, I mean, we find a parathyroid that's abnormal, we take it out, we find something, lymph nodes that are abnormal, we take them out. We don't wake the patient up, we don't talk to them. Now, when it comes to innovation, I think you're absolutely right. Most innovation in surgery is not the big device that costs millions of dollars. It's in fact, surgeon trying something different. So again, the SUS task force said three categories. Category number one, a minor modification of accepted technique. So that's where surgeon says, well, I usually do it this way, but in this case, instead of putting stitches in the intestine to put it back together, I'm gonna put you staples. Everybody would say, you're making a minor change. That's tinkering. It doesn't matter. You don't have to get prior authorization. You don't have to give consent. There's no disclosure, no regulation at all. There's another category, which is something that's innovative. So it's beyond what a standard accepted practice sort of locally. And that's where the feeling is if it's planned innovation, the surgeon should discuss that with a patient preoperatively. And if it's unplanned, I found something, I had to do something different, it should be disclosed soon as the patient's able to participate in that decision. Now that's the area. This innovation area is where there is no oversight. It's completely dependent on the individual surgeon to disclose or inform if it's planned or unplanned. And that's where I would say the primary discussion has to be about how do we handle those circumstances. Now, there's another issue, which I haven't really touched on, which is if I try it out and it works, and I say, hey, that's a good way to do it. I'm gonna do it again, the next case. And I do it the next case and it works really well. And now I say, you know what? I do it a third time. It's great. I say, you know, the next 10 patients, I'm gonna do it the same way and then I'm gonna write about it. Well, now that's research. Research has significant oversight. We go to an IRB, they're separate informed consent, right? But there's no oversight when I'm just trying to solve a patient's problem. So I think that you're right. That is a circumstance in which we depend on the professionalism of surgeons. I have a question for you about the side of the hospital. So if you are going to do something new, right? So you just mentioned this tinkering, but what bar is there for you not to bring in, you know, some new scope from Japan to use and what review that system had. I think you scored it around it, but I didn't get a clear answer. So you can maybe help me. And then I have a question a little more provocative. So the other thing, you've been talking about patient provider perspective, self-regulation. You mentioned at one point maybe patients should have who want to get the newest technology should pay for that. Right. Right. So, but that's a different burden, right? So where's the burden on a community of people to allow for innovation for surgeons, right? In the past, it used to be the downtrodden we're gonna experiment on them, so to speak, right? Now you're saying high tech hospitals we experiment on you and you pay for that potentially. Right, so there's the communal question or the societal question is still a little bit murky and I didn't quite get what your lasting point for us was on that or the teaching point. Well, where's the now societal burden for innovation? The next patient might do better. Sure. So while we talk about regulation, I still didn't get, well, what you think we should go towards, right? For these, this group, because we have to have surgeons doing things that are important and maybe make some mistakes while doing that. Right. Yeah, I guess I haven't answered the question because I don't know the answer. I think that it seems to me that from a societal, from a, you know, if you look at the whole society, an innovation like laparoscopic cholestectomy was a good thing. I think it's a good thing because it reduces morbidity and mortality and patients can resume their activity sooner and so I think that that's good for society. Now, during the course of getting to the point where we got that benefit, there were a lot of patients who had very long operations to have their gallbladders taken out and there were in fact many more patients that had complications, common duct injuries, things like that, that we didn't see for the open technique, okay? So there was a period of time where there was increased cost and increased risk. Now, I guess it seems to me that we have to look at every single innovation and think about what are the potential benefits before we can decide who should bear the burden, okay? So if it is in fact the case that we have an innovative technique to treat, for example, lung cancer, okay? And if that innovation may result in societal improvement, then maybe that isn't something that should be borne by the individual patient. But if the potential benefit of the innovation is a cosmetic benefit or a slight improvement in quality of life for an individual patient, then it seems to me that we have to think a little bit more carefully about should the burden of that new innovation be shared by the entire society or not? And again, I don't know the answer. I think that as we move forward, I'm not sure our health system is gonna be able to tolerate every surgeon who says, hey, I think I'm gonna use the robot to do that, just doing it. Dr. Podela's question reminded me of a very famous essay written in the 1970s by Hans Jonas. Jonas was a great philosopher of science who in those days was actually on the faculty here in the Committee on Social Thought. And has anybody in the room read this essay on clinical research? Mary has, but in that essay, Jonas says exactly what you said that in the past, the burden of new techniques and new research has largely been borne by the poor and they were often recruited to participate in clinical trials. He felt that it ought to be the wealthy and the best educated, the most powerful members of society who should be the first to be offered new techniques, new innovations. And it may be that bringing these new innovations through fancy hospitals, through their marketing departments, ends up doing exactly what Jonas had in mind. Because I mean, this complicated five-hour robotic surgery has gotta cost a fortune, I mean, to buy the robot and to play with it. So maybe we're seeing an application of Jonas's ideas about the most educated, the most powerful people in society. Shouldn't we have a regulation to share the innovations? Now the problem is everybody wants to be the first at everything. And there are 16 innovations being tried at the same time, of which the majority don't work, the minority work. So there's 16 places doing frontal abectomies. And why don't we share them? Why isn't there a regulation that different tertiary care centers who have the imperative to be the first of everything decide, pick three, and get burnt and burn their patient and do the learning curves and learn how to do it better, and then they share? I'm for competition, but not that extensive competition. Yeah, so the question for those of you who didn't hear, and I'll just paraphrase, was with respect to the learning curve, why don't the groups that are the hospitals, the high tech hospitals, the academic centers, why don't they sort of work together to sort of scale that learning curve and figure out what works, rather than compete with one another? And I think that it's an excellent point, and it would be a more rational approach to how we do things. Well, it could be regulated, I think that in the US it's very difficult because there's so little regulation of medical care at all. And so in that sense, it's very hard for, you know, especially in surgery, it's very hard for someone to tell me that I can't take care of my patient the way I want to. But I would agree with you that it's something that I think as we move forward, we have to think about new models, we have to think about new ways of doing it, and that may be the way that we have to go. So anyway, thank you all very much for your attention, it's really been a lot of fun. Thanks.