During my halcyon college days, long before I knew I would “grow up” to be a surgeon, I was a huge fan of Star Trek. Although the ideas behind warp speed travel and teleportation were mind blowing, I was even more captivated by “Bones” McCoy’s Tricorder. This and other similarly nifty little medical devices could in the hands of the right doctor affect surgical-like cures for most any disease non-invasively and without pain.
Who wouldn’t want to embrace such a future for medicine?
What exactly was McCoy’s Tricorder doing? Was it surgery? And for that matter, what is surgery? For virtually every human, including most physicians and even surgeons, the answer seems self-evident. Surgery involves the cutting of human tissue, and addresses all the consequences, such as reconstruction, pain, hemostasis and infection. “Cutting” into us vertebrates, of course almost by definition, entails pain, which in a nociceptive adverse species like ours, resulted in the invention and now commonplace use of anesthesia. Few surgeons would even question this viewpoint of their chosen vocation.
Perhaps the above “self-evident” definition of surgery is far too facile. For example this description of surgery largely misses the foundational practices of orthopedics, where the “non-invasive” reduction of bone fractures most commonly involves no cutting.
Meanwhile it is universally acknowledged that almost all surgical disciplines today execute their craft with ever-smarter medical devices and less and less cutting. The once time-honored surgical procedures for obliterating cerebral aneurysms, replacing aortic valves and reconstructing gastro esophageal junction have been replaced with percutaneous or trans natural orifice operations. Surgery just keeps getting “smaller,” to the point that now some procedures involve no true “cutting” whatsoever. Instead these ultra modern or emerging procedures invented by surgeons utilize directed energy to change tissues. High intensity focused ultrasound (HIFU) and stereotactic radiosurgery (SRS) being clear cases in point. In fact, stereotactic radiosurgery has quietly emerged over the past few years as the single most common surgical billing CPT code (61796) for brain tumor in the United States, and in doing so, this “surgical” procedure has transformed much of modern brain surgery.
The undisputed “father” of neurosurgery has always been Harvey Cushing, who, almost 80 years past his death, still towers over my chosen specialty. In the context of this blog it is worth reminding that Cushing himself was once asked about the nature of surgery. He is quoted as saying “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least of the work.” Surgery has always been a form of tool-centric art grounded in science, and is as much a discipline of thinking as anything else. Perhaps this is part of what Cushing, a gifted artist himself, was trying to say.
So why are any of these musings relevant? Because we humans cannot invent that which we cannot imagine, and if our imagination is limited by past definitions, which are themselves burdened with regressive billing codes, so too will our future surgical creations. It is a sad irony in the absurd world of healthcare today that surgical billing codes drive invention, and not the other way around. In the spirit of Bones McCoy I truly hope surgeons now and in the future will seek to define ourselves in the most expansive Cushing-like terms as we reinvent our craft – The Cureus Journal of Medical Science will be ready and waiting to report on exciting new surgery technologies. After all, our patients in the 22nd century will be holding us accountable.