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What is the point of surgery?
Editorial
On an individual level, surgery relieves pain, restores function, improves quality of life, and saves lives. In what manner and to what end do these services engage in broader terms with the health of populations? 1 year ago, The Lancet published a surgery-themed issue that introduced the IDEAL recommendations to improve surgical research. In that issue, Ara Darzi and colleagues challenged surgeons to transform their specialty into a word-class discipline. Today’s Lancet returns to the theme of surgery to assess what progress has been made. Recent headlines in the UK suggest not so much a worldclass discipline but a profession adrift. On Sept 16, 2010, the UK National Confidential Enquiry into Patient Outcome and Death published a report on the organisation of cosmetic surgery in the UK. Despite a statutory obligation to participate in audit, only 47% of 760 eligible centres responded. Even in those units that replied, concerns arose over low-volume procedures, inadequately equipped operating theatres, anaesthetic cover, and emergency care provision. That such revelations must come from outside the surgical community implies a lack of professionalism and leadership among the surgeons involved. Against such a background of existential crisis, it is appropriate that the theme for this year’s Clinical Congress of The American College of Surgeons (ACS) in Washington, DC on Oct 3–7, 2010, is professionalism in the 21st century. LaMar S McGinnis Jr set out a clear vision of surgical professionalism when he was elected president of the ACS in October, 2009. He does not distinguish between professionalism of the surgeon and the person, nor between the craft and other elements in life. Thus, he maintains, civic professionalism should be expressed in the non-clinical lives of surgeons, particularly in advocating for equity at local, national, and global levels. How such a vision of professionalism can be translated into daily practice is illustrated in The Lancet today, which examines ethics, evidence, and equity in contemporary surgery. Two Viewpoints address, respectively, the ethics of the Spanish Model of organ donation (by David Rodríguez-Arias and colleagues) and of research in surgery (by Jane Johnson and co-authors). Ethics and individual patients’ decisions also feature in Peter Angelos’ Art of medicine essay. Evidence that endarterectomy reduces stroke more effectively than stents in people with carotid stenosis www.thelancet.com Vol 376 September 25, 2010
is strengthened by two Articles: the Carotid Stenting Trialists’ Collaboration’s meta-analysis of short-term outcomes in symptomatic disease, and a long-term follow-up from the Asymptomatic Carotid Surgery Trial. These studies are a testament to the value of time and volume to clarify surgical outcomes. Luke Funk and colleagues show the potential importance of surgery as a means for health equity in their estimation of operating theatre distribution. They found that a third of the world’s population, those with the greatest burden of surgical disease, had the lowest access to surgical facilities. Additionally, more than half of the operating theatres in developing countries did not have pulse oximeters. In an accompanying Comment, Paul Myles and Guy Haller muse on the implications of these findings for children’s surgery in developing countries. A common theme in Funk’s paper and the report on UK cosmetic practice is that substandard facilities threaten patients’ outcomes. Surgeons, as patients’ advocates, should be active and united in drawing attention to inadequacies as part of an agenda of reform that promotes professionalism and leadership. But surgeons are largely absent from the debate, and—with one or two notable exceptions, such as Bruce Keogh in the UK—the profession is visibly absent from higher positions in health care. Is this because surgery is too fragmented into subspecialties, too introspective, or too disinterested? Change is needed; as are more people like Atul Gawande (see Profile), a co-author of Funk, who can interact with multiple stakeholders, and communicate surgery, research, and politics in an engaging manner that commands public and professional support. Surgeons are renowned for imaginative solutions, translating ideas into practice, and for leading teams. All these skills are needed to redefine surgery’s role and extend its benefits to wider populations. By uniting stakeholders and identifying opportunities, surgeons can help to overcome disparities within and between health-care systems. Broadening surgical influence effectively requires strong, visible leadership and a commitment to education that develops the core principles and unique skills of the profession; otherwise surgery’s noblest aspirations risk being subsumed by the basest common interests. ■ The Lancet
Science Photo Library
What is the point of surgery?
See Comments pages 1027, 1028, 1031, 1033 and 1034 See Perspectives pages 1043, 1044, 1045, and 1046 See Articles pages 1055, 1062, and 1074 See Viewpoint pages 1109 and 1113
For the National Confidential Enquiry into Patient Outcome and Death report on cosmetic surgery see http://www.ncepod. org.uk/cs.htm
1025
On an individual level, surgery relieves pain, restores function, improves quality of life, and saves lives. In what manner and to what end do these services engage in broader terms with the health of populations? 1 year ago, The Lancet published a surgery-themed issue that introduced the IDEAL recommendations to improve surgical research. In that issue, Ara Darzi and colleagues challenged surgeons to transform their specialty into a word-class discipline. Today’s Lancet returns to the theme of surgery to assess what progress has been made. Recent headlines in the UK suggest not so much a worldclass discipline but a profession adrift. On Sept 16, 2010, the UK National Confidential Enquiry into Patient Outcome and Death published a report on the organisation of cosmetic surgery in the UK. Despite a statutory obligation to participate in audit, only 47% of 760 eligible centres responded. Even in those units that replied, concerns arose over low-volume procedures, inadequately equipped operating theatres, anaesthetic cover, and emergency care provision. That such revelations must come from outside the surgical community implies a lack of professionalism and leadership among the surgeons involved. Against such a background of existential crisis, it is appropriate that the theme for this year’s Clinical Congress of The American College of Surgeons (ACS) in Washington, DC on Oct 3–7, 2010, is professionalism in the 21st century. LaMar S McGinnis Jr set out a clear vision of surgical professionalism when he was elected president of the ACS in October, 2009. He does not distinguish between professionalism of the surgeon and the person, nor between the craft and other elements in life. Thus, he maintains, civic professionalism should be expressed in the non-clinical lives of surgeons, particularly in advocating for equity at local, national, and global levels. How such a vision of professionalism can be translated into daily practice is illustrated in The Lancet today, which examines ethics, evidence, and equity in contemporary surgery. Two Viewpoints address, respectively, the ethics of the Spanish Model of organ donation (by David Rodríguez-Arias and colleagues) and of research in surgery (by Jane Johnson and co-authors). Ethics and individual patients’ decisions also feature in Peter Angelos’ Art of medicine essay. Evidence that endarterectomy reduces stroke more effectively than stents in people with carotid stenosis www.thelancet.com Vol 376 September 25, 2010
is strengthened by two Articles: the Carotid Stenting Trialists’ Collaboration’s meta-analysis of short-term outcomes in symptomatic disease, and a long-term follow-up from the Asymptomatic Carotid Surgery Trial. These studies are a testament to the value of time and volume to clarify surgical outcomes. Luke Funk and colleagues show the potential importance of surgery as a means for health equity in their estimation of operating theatre distribution. They found that a third of the world’s population, those with the greatest burden of surgical disease, had the lowest access to surgical facilities. Additionally, more than half of the operating theatres in developing countries did not have pulse oximeters. In an accompanying Comment, Paul Myles and Guy Haller muse on the implications of these findings for children’s surgery in developing countries. A common theme in Funk’s paper and the report on UK cosmetic practice is that substandard facilities threaten patients’ outcomes. Surgeons, as patients’ advocates, should be active and united in drawing attention to inadequacies as part of an agenda of reform that promotes professionalism and leadership. But surgeons are largely absent from the debate, and—with one or two notable exceptions, such as Bruce Keogh in the UK—the profession is visibly absent from higher positions in health care. Is this because surgery is too fragmented into subspecialties, too introspective, or too disinterested? Change is needed; as are more people like Atul Gawande (see Profile), a co-author of Funk, who can interact with multiple stakeholders, and communicate surgery, research, and politics in an engaging manner that commands public and professional support. Surgeons are renowned for imaginative solutions, translating ideas into practice, and for leading teams. All these skills are needed to redefine surgery’s role and extend its benefits to wider populations. By uniting stakeholders and identifying opportunities, surgeons can help to overcome disparities within and between health-care systems. Broadening surgical influence effectively requires strong, visible leadership and a commitment to education that develops the core principles and unique skills of the profession; otherwise surgery’s noblest aspirations risk being subsumed by the basest common interests. ■ The Lancet
Science Photo Library
What is the point of surgery?
See Comments pages 1027, 1028, 1031, 1033 and 1034 See Perspectives pages 1043, 1044, 1045, and 1046 See Articles pages 1055, 1062, and 1074 See Viewpoint pages 1109 and 1113
For the National Confidential Enquiry into Patient Outcome and Death report on cosmetic surgery see http://www.ncepod. org.uk/cs.htm
1025