Although it's clearly much safer, as Winston Churchill liked to say,
to advance a prophesy only after the event has taken place, this month
we have thrown caution to the winds and attempted to paint a rough picture
of what outpatient surgery will look like one decade hence. In the pages
that follow, visionaries prognosticate on surgical technology, anesthesia,
ophthalmology, gastroenterology, orthopedics, plastic surgery and the
future of outpatient surgery facilities in the year 2010. In the meantime,
this bold prediction: The next 10 years will hold both good news and bad
news. The outpatient surgery market should continue its phenomenal growth.
But pressures on payment will continue, while costs-especially the cost
of labor-will continue to rise.
SMG Marketing projects that the outpatient surgery market, currently
at about 33 million cases per year, will grow to 42 million by 2006. If
this growth continues until 2010, there will be about 48 million cases
being done in 2010 on an outpatient basis.
Helping to fuel this growth may be elective procedures. In the last year,
the number of liposuctions grew by 34 percent and the number of breast
augmentations grew by 26 percent. Nearly a million LASIK refractive eye
procedures were done last year, making this the No. 1 elective procedure
in America.
Surgery may also continue to decentralize, but at a slower pace. Since
1980 hospitals have lost a third of their market share to alternate sites.
Today, the growth of ambulatory surgery centers may be slowing; they only
grew by 2 percent in 1999, according to SMG. Office-based surgery facilities
continue to grow at a heated 11 percent annual clip, but recent deaths
in office surgery settings could stimulate increased regulation, slowing
this growth as well.
In the midst of this growth, reimbursements for Medicare and commercial
insurance may continue to drop. In 2005, the first of the Baby Boomers
will begin to retire, adding strain to a system that is already running
in the red. Right now, the annual growth in spending per Medicare retiree
is projected at 5 percent. To get the program back on sound footing, it
needs to be 4 percent. Commercial insurance is in the same shape, with
many insurers losing money and raising rates. Employers will seek to regain
control of costs, all of which will squeeze health care providers further.
One of the most significant problems will be labor. Because nursing
is no longer attracting as many youngsters as it once did, the average
registered nurse is 42 years old, more than four years older than he or
she was in 1983. The number of nursing hours available will peak in 2007,
and then will start to decline. By the year 2020, supply will fall 20
percent short of demand. Competition for nurses will increase and so will
wages.
As no one can know the future, the predictions in the following pages
likely are highly imperfect and perhaps even wrong. Yet it is our hope
that this exercise will help you refine your own thoughts of what is to
come, and empower you to help shape it to your liking.
A Peek into The OR of the Future
Yasmine Iqbal, Editor
The blistering pace of medical advances set in the late 20th century
will not abate in the 21st. Companies, engineers, and surgeons will continue
to conceive and develop hi-tech marvels, although ever-increasing cost
constraints will ensure that the gadgetry that makes the cut isn't just
for show. A few predictions:
Smaller incisions
Within the next 10 years, minimally invasive surgery will become even
less so. Carlos Gracia, MD, an MIS expert at ValleyCare Medical Center
in Pleasanton, Calif., believes 3 mm laparoscopic incisions will be standard,
resulting in "less pain and less scarring." He recently oversaw the implementation
of Karl Storz's OR 1 integrated laparoscopy system in one of his hospital's
ORs; he says the higher resolution video that the system provides has
already allowed him to shrink his incisions.
Robotics
FDA's recent approval of the DaVinci surgical robot may foreshadow a time
when microsurgery is safer and fewer scrub nurses are necessary.
The device, made by Intuitive Surgical, consists of a console, where
the surgeon views and controls the procedures, a 3-D vision system, and
a table where three robotic arms maneuver endoscopic instruments.
Randolph Chitwood, MD, chief of surgery at East Carolina University,
says the system is particularly useful for fine maneuvers; it automatically
filters out tremors and translates the surgeon's macro-movements into
micro ones at the business end. He likens working with the 3-D, 10x magnification
image to "walking on the lunar surface."
Craig Owens, MD, a surgeon at Henrico Doctors Hospital in Richmond, Va.,
agrees, but says there are still glitches. Set-up is "a big project, which
definitely increases turnover time," and he adds that it's actually less
convenient. "Even though the surgeon doesn't have to be sterile to perform
the procedure at the console, he has to scrub in to place the trocars
before the procedure, and scrub in afterwards to close the wound."
The machine also does not provide haptic feedback, although Dr. Chitwood
believes this problem may be solved within the next few years.
A final issue is price; DaVinci costs $1 million. So far, 21 have been
installed worldwide, but it's hard to say how quickly that number will
grow. Says Dr. Gracia: "Robotics is sexy and fascinating, but robots have
a long way to go before they add value."
Virtual training
Surgeons, like pilots, will hone their skills with video simulations.
At St. Peter's University Hospital in New Brunswick, NJ, the Minimally
Invasive Skills Training Center is stocked with anatomical models, robotic
systems, computers, and high-resolution monitors to help residents learn
and perfect minimally invasive techniques before they operate on patients,
according to Peter Geis, MD, chairman of surgery. As students practice
procedures, the equipment tracks precision and speed, providing a "score"
that they can try to beat the next time. Students at remote sites can
participate, too, through interactive video hookups. "This will be the
way all residents are taught in the future," opines Tim Hosea, MD, an
instructor at the center.
Other ways that the OR of the future may change:
- Voice-recognition will allow surgeons and staff to dim lights, reposition
the table and control robot assistants, says Dr. Geis.
-The resolution of laparoscopy monitors will increase dramatically, says
Skytron's Randy Tomascewski. They'll also be flatter and easy to maneuver,
so they can be brought close to the patient without compromising the sterile
field.
- Some surgeons may start wearing heads-up monitors, which will allow
them to see their hands and the screen at the same time, says Olympus's
Stacy Persky.
- ORs will store instruments in "smart walls," which will replace booms
and keep equipment out of the way, says Ms. Persky.
- Data ports and cords to connect devices will disappear, says Ms. Persky,
and be replaced by infrared beams.
- Surgeons will be able to pull up any part of the patient's medical record
on the monitor while at the table, says Ms. Persky.
- More instruments and devices will be designed to be reprocessed and
reused safely, says Dr. Owens. Saving on costs will continue to be a key
driver.
Technology may never replace skill, but it will continue to help surgeons
push the limits of what they're able to achieve, making the once-unimaginable
doable and the once-impossible commonplace.
Anesthesia in 2010: More Precise, Less Invasive
– and Drug Free?
Theodore Stanley, MD Salt Lake City, Utah
Ten years hence, we'll be able to administer anesthesia and analgesia
with great precision and with very little pain. The tools we use will
be more effective, promote faster patient recovery, and cause few or none
of the side effects with which we now grapple.
Right now, patients receive anesthesia and analgesic drugs intramuscularly,
intravenously, orally, or rectally. By 2010, we may administer them through
the skin.
People have been applying analgesic ointments and creams for local analgesia
for centuries. If we could do the same with systemic analgesics, we might
be able to prevent gastrointestinal degradation that results from oral
analgesics. We might also reduce the variability of serum drug concentration
profiles, eliminate peak and trough concentrations, and improve drug safety
by reducing the high plasma concentrations that often occur when we administer
drugs intravenously or intramuscularly. Transdermal delivery also might
simplify dosing schedules, reduce dosing frequency and decrease the pain
and discomfort associated with other drug delivery methods.
Already, we've had some success in using transdermal fentanyl patches
for post-op pain. But there are side effects, including post-op nausea
and vomiting and a long-term residual effect.
Perhaps we'll be able to enhance and control transdermal drug delivery
by using iontophoresis, which is a way of propelling drugs through the
skin via electrodes that deliver a controlled electric current. We've
already successfully administered lidocaine and steroids using this technique,
and in 10 years, we may be administering many more drugs this way. We
will even be able to adjust the dosage of the drug and halt drug delivery
by adjusting the current.
We may also be able to deliver anesthesia and analgesia more selectively
and exactly when desired, a concept known as "drug focusing." We might
do this by encasing inactive forms of drugs in microscopic lipid envelopes
and injecting them into the bloodstream, where they will travel to the
site where we want them to work. We will then focus a microwave, ultrasonic,
or other energy wave form to break the lipid bag. This will release the
compound where it's needed, without systemic effects.
Possibly we'll be able to create anesthetic effects without using drugs
at all. We may do this via transcutaneous electrical stimulation. By 2010,
we may have found energy sources that, when properly focused, can interfere
with nerve conduction. We may routinely outfit patients with a helmet
or series of electrodes that deliver controlled electric current to the
brain and block pain sensations, creating anesthesia and analgesia without
drugs.
In the mid-1800's anesthesia revolutionized surgery by making it possible
to do complex procedures by putting patients to sleep. As procedures become
more complex, anesthesia will keep pace by making even major procedures
practically pain free.
Dr. Stanley is a professor of anesthesiology and professor of surgical
research at the University of Utah School of Medicine and has been a clinical
research investigator for numerous companies in the investigation of new
anesthetic drugs.
Ophthalmology in 2010: A Vision of the Future
Dan Durrie, MD Kansas City, Mo.
A decade from now, I believe much more eye surgery will be done than ever
before. But the reasons for surgery, the way we do it and the person who
does it may change dramatically.
By the year 2010, we eye care professionals will have divided up patients'
lives into three or four visual periods.
The developmental period will last from birth through age 20. During
this stage, the eye's refraction continues to change, so we'll still be
prescribing contact lenses and glasses. However, the way we do that will
be different. Right now, we still measure refractive status with a century-old
system-we place spherocylindrical lenses in front of the eyes until the
patient tells us which one he likes best. Technologies just now coming
into use, including ray tracing and wavefront analysis, will make refraction
much better. The patient will look into a device that will precisely decide
the ideal correction and grind either a pair of glasses or contact lenses
suited to the patient. The 20/20 benchmark will no longer be in place;
people will routinely be able to see 20/10 or better.
The second period will last from the 20s through the early 40s. During
young adulthood, a large percentage of ametropes will get their corneas
reshaped or undergo implantation of an intraocular lens to augment their
natural lens. To choose lens power, we'll use the same measuring devices
mentioned earlier. If the patient's eye or lifestyle changes, we will
"touch up" the refraction by using a laser to sculpt the implant or sculpt
the cornea intrastromally.
When these patients start becoming presbyopic at age 43 or so, they will
have entered the third visual period. Now they will have their crystalline
lenses replaced with accommodating IOLs that allow them to see near and
far. Bifocals and cataract surgery will disappear.
If we've not yet found a cure for macular degeneration, some of our patients
will undergo a fourth operation at age 75. We'll add a high-magnification
or telescopic lens that redirects the central image to healthy retina.
By 2010 we will have many more laser wavelengths at our disposal; there
will even be a device that automatically makes the corneal incision and
the capsulorhexis.
We surgeons will still be in charge of emulsifying the crystalline lens
and aspirating it, but we will use a laser and a needle rather than phaco
and I/A. By this time, five-minute cataract operations will be considered
slow.
Although we'll be doing more surgery, there will be less demand for surgical
skill. Ophthalmologists will supervise four or five techs and do a lot
less hands-on work.
We will be able to do operations long-distance, via the use of real-time
video and robotics. Today surgeons send me corneal topography, and I recommend
an incision at a certain place. In 2010 I will be making that incision.
This will enable us to care for patients in third world countries, where
cataract, appallingly, is still a leading cause of blindness.
Of one thing I am absolutely positive: More of us will be seeing better
and more conveniently than ever. And if vision truly is our most delightful
sense, as Joseph Addison said, then we can look forward to better, happier
lives as well.
Dr. Durrie has helped develop many of the refractive surgery techniques
in use today.
Gastroenterology in 2010: Making the Previously
Incurable Treatable
Bergein Overholt, MD Knoxville, Tenn.
Today, colorectal cancer is the second leading cause of cancer death.
Ten years from now, it will not be. Advances in diagnostic and treatment
techniques will help endoscopists find and treat polyps well before they
develop into malignant tumors. Surgeons will also become adept in treating
and curing advanced colon cancer and many other previously untreatable
chronic digestive disorders.
Colonoscopy will be the screening method of choice for colon cancer,
for both high- and low-risk patients. Flexible sigmoidoscopy, already
proven to be much less effective for finding polyps beyond the lower colon,
will be almost completely disregarded as a screening tool.
Colonoscopies will become easier for endoscopists and patients because
we'll be better trained in insertion, and the scopes will be easier to
use. Already, the variable stiffness endoscope is beginning to revolutionize
colonoscopy. This device makes it much easier to advance through the redundant,
or floppy, areas of the colon. In the future, endoscopists may rely on
mechanical push-pull systems to advance the scope to the cecum; one method
under development involves lining the outside of the scope with a series
of tiny balloons, which inflate and deflate automatically, helping to
inch the scope forward.
Advances in imaging will also help endoscopists diagnose potential tumors
much earlier. High-magnification lenses and contrast dyes will allow us
to distinguish and treat potential malignancies at the cellular level,
before they become full-fledged polyps or tumors. We will also use ultrasound-enhanced
endoscopes to see the layers of the walls of the digestive tract, allowing
us to discern tumor depth.
Imaging technologies will help us perform virtual colonoscopies, which
are in limited use right now. In these, the patient undergoes a rapid
spiral CT scan, which creates an X-ray reconstruction of the colon. This
technique offers several advantages over traditional colonoscopies: It
is less invasive, less expensive ($800 vs. $1,200 for a colonoscopy),
shorter (10 minutes vs. 30-45 minutes), and less risky, since there's
no chance of accidental perforation. It won't replace traditional colonoscopy,
though, because it can't detect polyps smaller than 8 mm and won't allow
treatment-if we find a polyp, the patient will have to undergo colonoscopy
to remove it. While some patients may prefer to undergo the traditional
test and be done with it, the virtual test may help screen patients who
otherwise wouldn't undergo colonoscopy.
We'll also be able to examine the small intestine more easily. Already,
one company has developed an "imaging capsule" to diagnose lesions in
the small intestine. The capsule contains a tiny camera; after the patient
swallows it, it travels through the digestive tract and transmits images
to a recorder worn on the patient's waist.
The next 10 years will also bring less invasive, more effective methods
of treating other digestive disorders, such as gastroesophageal reflux
disease.
One technique we'll use is endoscopic suturing. The surgeon uses a sort
of miniature sewing machine attached to the end of an endoscope to place
sutures in two different areas near the lower esophageal sphincter; he
then ties the sutures together to tighten the valve, preventing the stomach
acids from flowing up.
Another method, called the Stretta technique, involves placing a balloon
with small wires in the lower end of the esophagus. The wires heat up,
destroying the nerves and altering the sphincter muscle to stop reflux.
A third method involves injecting inert material into the sphincter to
produce enlargement and bulging, reducing reflux.
We'll also be using photodynamic therapy, lasers, and ultrasound to treat
Barrett's esophagus. We'll treat the area with a photosensitive drug,
insert a balloon to open and flatten the folds of the esophagus, then
pass a light or laser probe into the balloon to activate the drug and
selectively destroy the esophageal lining.
In the future, better drugs may prevent or treat some of the digestive
conditions that plague us today. Surgeons will also be able to treat conditions
such as advanced colon cancer that today may be a death sentence. The
future is limited only by our vision, and our vision is limitless.
Dr. Overholt's group established the first practice-based endoscopic
ASC in the country.
Orthopedics in 2010: Entering the Biological
Era
Louis W. Meeks,
MD, FACS Boston, Mass.
Cartilage and ligaments, which do not spontaneously repair and respond
poorly to intervention, represent the next great orthopedic frontier.
Within the next 10 years, we will make great inroads in our ability to
repair these soft tissues as we learn how to apply gene therapy and tissue
engineering technologies that promise to pick up where nature left off.
We will be able to hasten ACL graft ligamentization, improve the success
of cartilage transplants, and even grow fully mature ligament, nerve,
and cartilage tissues from stem cells.
Advances in Ligament Repair
More than 100,000 ACLs rupture each year in the United States, and
ligaments can take up to 18 months to reach full strength after reconstruction.
Gene therapy (Figure 1) and tissue engineering promise to not only hasten
graft healing but significantly decrease morbidity and perhaps even produce
a stronger, more resilient ligament.
In the future, surgeons will deliver growth factor-producing genes, which
promote musculoskeletal tissue healing, to the ligament either during
graft implantation or before ACL reconstruction. During reconstruction,
the surgeon may also deliver genes that produce bone morphogenic protein
to the femoral and tibial tunnels. This will hasten tendon-to-bone healing,
a problem when using autologous semitendinosus and/or gracilis tendon
grafts.
Tissue engineering technology will also offer surgeons the potential
to replace damaged ACLs and other ligaments with fully engineered ligaments
grown inside or outside of the body. Researchers have already cultured
ligament tissues in vitro by seeding ACL cells onto synthetic biodegradable
polymeric fiber scaffolds or stents. The researchers are ‘designing' these
grafts to have improved viscoelastic properties and less creep (stretching
of a ligament replacement graft) than conventional grafts. Research is
also well underway to replace the conventional ACL graft with a collagen
matrix impregnated with multipotent stem cells. These specialized stem
cells can then differentiate and grow into a new ACL in vivo. This may
do away with autograft harvesting and eliminate the risk of infectious
disease transmission and immunorejection posed by allografts. We still
must find a way to ensure strong graft fixation and overall biomechanical
integrity, however.
Cartilage Repair
In 10 to 15 years, many of the 220,000 joint replacements we perform
each year may be unnecessary. By then, we may be using gene therapy to
prevent post-traumatic arthritis, halt the progression of existing arthritic
conditions, and successfully fill articular surface defects.
Already, researchers have successfully used gene therapy to inhibit cartilage
breakdown and stimulate chondrogenesis. Initially, this may necessitate
repeat injections into the articular cartilage, but single-injection treatments
for trauma patients will be possible.
In addition, it may soon be possible to use gene therapy to halt both
rheumatoid and osteoarthritis. Researchers are now using viral vectors
to carry an antagonist protein to the affected joints of rheumatoid patients.
This protein suppresses interleukin-1, a powerful enzyme that degrades
articular cartilage. Another protein called transforming growth factor
beta shows similar promise for osteoarthritis patients.
Other Repairs
Gene therapy and tissue engineering also promise to improve the outcome
of current meniscal allografting techniques (which now fail in up to 60
percent of cases after two years), promote osteogenesis in patients with
impaired fracture healing or stress fractures, and hasten healing of severely
injured muscles-a potential boon to sports medicine.
A Bright Future
As with nearly any budding medical technology, gene therapy and tissue
engineering have downsides. Congress is now debating the ethics of stem-cell
research and has yet to decide if the government should provide public
funding. Researchers are also scurrying to find new gene vectors (the
messengers that deliver the genes to the target tissues), as the commonly
used adenovirus vector can pose safety problems. Growth factors also tend
to die within four to six months, and patients with chronic conditions
may need gene therapy for a lifetime.
Despite these challenges, clinical orthopedics has left the biomechanical
age and has entered the biological era. There is a great force driving
gene therapy and tissue engineering research, and these new technologies
will become a reality for arthroscopic surgeons and sports medicine physicians
within five years.
Dr. Meeks is a pioneer in the field of arthroscopy
and performs more than 600 major orthopedic procedures each year.
Plastic Surgery in 2010: A Routine Part of Wellness
Rod Rohrich, MD Dallas, Texas
In 10 years, cosmetic surgery will be a part of almost everyone's wellness
routine, as immunizations are now. It will also be less invasive, safer,
and easier to recover from. Cosmetic surgery will become cosmetic medicine,
a part of the complete cycle of wellness.
When patients enter their late teens or twenties, they will schedule
a visit–with either a plastic surgeon or even a primary care physician–for
a comprehensive three-dimensional computer body mapping, in an MRI-like
device. This procedure will record body contours while patients are "in
their prime." We'll be able to show patients how age will affect their
bodies and which procedures they'll need. We'll also use this as a reference
when it's time to restore the patient's youthful appearance.
During the same visit, we'll extract some fat and skin cells, which we
will clone and preserve for future body and face sculpting. By the way,
cloned fat cells will be the material of choice for breast enhancement
and reshaping; we'll no longer use silicone or saline implants.
The way surgeons perform cosmetic surgery procedures will also change.
Instead of performing liposuction manually with a hand-held device, surgeons
will enter into a computer the precise location and amount of fat to be
removed. A robot-assisted liposuction unit will help perform the procedure
with absolute precision. The cannulas will be much smaller, making the
technique much safer and minimizing recovery time. We may truly be doing
"lunchtime liposuction" and facial rejuvenation.
Technology will enhance our artistic capabilities, but not replace them-only
the best-trained surgeons will be able to produce the best and safest
results. Patients will have greater access to the best and brightest,
though, via telemedicine and virtual surgery. Soon, surgeons will be able
to consult with, examine, and actually perform procedures on patients
several states, or even continents, away.
Ponce de León never did find the fountain of youth he sought in 1511,
but I believe that we're inching closer to discovering it in 2010. As
people live longer, healthier lives, they'll undoubtedly want to look
as good as they feel. Technical innovations and surgical skill will help
us advance the art of plastic surgery and give them the results they seek.
Dr. Rohrich is the co-editor of Journal of Plastic and Reconstructive
Surgery and chair of the Department of Plastic and Reconstructive Surgery
at University of Texas Southwestern Medical Center at Dallas.
Ambulatory Surgery Centers: Then and Now
Wallace A. Reed, MD Phoenix, Ariz.
When John L. Ford, MD, and I opened the doors of the first multispecialty
ambulatory surgery center in the US in 1970, we were formidable competitors
for our local hospitals. But today, I think the future lies in cooperation
rather than competition. The market is changing, and centers that work
with hospitals will be the ones that do well.
When we built our facility in Phoenix, we had a simple goal: We wanted
to create a safe, economical, high-quality alternative, where patients
could be given "red-carpet" treatment and the surgeons and nurses would
find less bureaucracy.
At the time, Phoenix hospitals were very busy and had little interest
in catering to the occasional ambulatory surgery case. They scheduled
these cases not in the main OR suite, but in poorly equipped emergency
rooms. Nurses were obliged to carry sterile packs from the main ORs to
the ER. Elective cases were cancelled or postponed whenever an emergency
patient showed up. Complaints fell on deaf ears.
Patients were also complaining. I remember an uninsured barber who told
us that he would have to do 250 haircuts (at $2 per haircut), to pay for
his two children's adenoidectomies.
Aided by that climate, we performed more than 2,400 procedures in our
facility in the first year. We received outstanding press, and soon many
others were building freestanding ASCs.
Soon, many of those centers will find their environments much more difficult.
Hospitals have become more attuned to ambulatory surgery and have demonstrated
that they can implement the same patient- and surgeon-oriented philosophy
at competitive rates. I believe that in the future many-if not most-freestanding
ASCs will find that they need to partner, rather than compete, with hospitals.
Consider the following:
- Medicare last month began reimbursing all hospital outpatient services
on a prospective payment system. While this may seem like a negative on
its face, I believe it will force hospitals to start taking a hard look
at their costs and find new ways to provide care more efficiently. This
is not good news for competing freestanding ASCs. Hospitals are already
well placed to compete for commercial insurance contracts due to their
ability to provide "soup to nuts" health care. If they are also able to
lower their costs, they'll be even more efficient.
- Federal and state agencies from Medicare to OSHA to state departments
of health continue to create more and more onerous regulations. Five states
even now require accreditation of office-based surgery facilities. If
regulation continues to increase-and I believe it will-smaller centers
will simply not be able to bear the cost of compliance.
- The addition of recovery centers, a gambit many ASCs are using to perform
more complex cases, won't work for most. I believe that a significant
number of these beds will stay empty much of the time, driving up overhead
and producing few meaningful benefits. Medicare does not seem any closer
to reimbursing ASCs for procedures that require 23-hour stays. Instead
of adding recovery care, ASCs may do better to partner with an independent
recovery care center or a hospital to provide post-op care.
- Although the shortage of OR personnel, particularly OR nurses, will
hurt all surgical facilities, smaller ones will be hurt the most. Alternate
sites do have benefits to offer, including holidays and weekends off.
But most nurses entering the workforce in the next 10 years will be attracted
to the fast pace, diverse caseload, and potential for higher pay that
hospitals offer.
It's crucial for those in the freestanding ASC community not to consider
hospitals the "enemy"; in fact, there always was, and will always be,
a need for both. Our centers have formed successful partnerships with
three hospitals; I believe such combinations will continue to form nationwide.
In the end, what's important is not where outpatient surgery is performed,
but that the outpatient surgery culture prevails. We need to cater to
patients and surgeons, and provide high quality, safe, cost-effective
care.
Dr. Reed is the only person to have served on the Federated Ambulatory
Surgery Association (FASA), the Society for Ambulatory Anesthesia (SAMBA),
and the Accreditation Association for Ambulatory Health Care (AAAHC).
