MAY 30, 2004

Can you teach an old doc new tricks?

Some contend surgeons are lounging on their laurels.
No, say others, the nation's scalpels are in good hands

"It's difficult to talk about this and be polite, but there's a certain reluctance to change and move on from what's comfortable."It all started with this quote. Dr Gopal Bhatnagar, Head of Cardiovascular Surgery at Trillium Health Centre in London, Ontario, went out on a limb and potentially set himself up for a fall when he was asked for his opinion on a new surgical technique called beating-heart surgery.

The quote ran in the Globe and Mail on April 21 concerning the technique, with no objection from Dr Bhatnagar, even though he knew that some of his surgeon colleagues wouldn't be pleased with the fiery accusation. His statement does beg the question: Are Canadian surgeons really that complacent when it comes to learning new skills?

Dr Bhatnagar doesn't like to point fingers, but he does believe that some Canadian surgeons are hesitant about changing with the times. He says it wasn't his intention to attack his colleagues directly, but to call attention to what he sees as a troubling trend in the Canadian surgical community. He feels that many surgeons work in a 'comfort zone.' "They want to do what's best for the patient and they often perceive what they do repeatedly as the safest," he says.

Some doctors in the field see things differently. Dr Bob Litchfield, Educational Director of the London-based Canadian Surgical Technologies & Advanced Robotics (C-STAR), is one surgeon who believes that Canada is a cut above the rest when keeping up with evolving technologies. "We aren't complacent in Canada," he says. "The motivating forces behind surgical advances are different here. We don't have the market forces that exist in the US. Here, we're doing what's best for the patient."

Dr Litchfield does concede that certain physicians are slower at jumping on the bandwagon. "There tends to be people who jump on every new technique and then there are those who sit back and wait," he says.

Late adopters usually prefer to wait for a prodigious pile of clinical data before taking on a new technique, something that Dr Bhatnagar acknowledges is an important step. "It's a matter of proof. For many surgeons, studies need to be done over a long period of time to convince them that the technique works," he says. "Every practitioner has to decide what the burden of proof is for them. Some surgeons need to see results from several randomized studies to know if something is clear."

The reluctance of one group ? be they the majority or not ? is counterbalanced by the vision of the others. Innovative surgeons pave the way for new surgical techniques ? Dr Bhatnagar with beating-heart bypass surgery and Dr Litchfield with minimally invasive techniques and robotics.

Besides reluctance, one of the things that can potentially put the brakes on skill set progress is funding. "Money is going to be an issue here in Canada," says Dr Bhatnagar. "Many of the minimally invasive techniques use scopes, clips and other components that cost a lot. In some ways the old techniques do cost less, initially. But newer techniques will save money in the long term ? less patient complications will mean less expenditures."

This is one point on which Dr Litchfield agrees with his colleague. "There is a saving in the long term when we treat with less invasive techniques," he says. But Dr Litchfield notes that Canada has maintained a position of being a world leader in new techniques and technologies. "I think we have continued to be quite fortunate because hospital administrators are responsive to new techniques and up for better patient care."

In order to continue along this path, the path of innovation needs to shift toward med schools and students. Teachers' attitudes and openness, as well as the students' receptiveness will dictate how surgery will evolve. "When I went to med school free thinking wasn't encouraged," explains Dr Bhatnagar. "You had to memorize reams of information and you repeated what you saw." Much of the future of a changing skill set will depend on how surgery is taught. He adds that educators should devise curricula that encourages students to push the envelope.

Dr Litchfield, who incidentally went to med school with Dr Bhatnagar, agrees. "We were spoon-fed what was in text- books," he says. But he does point to a change in attitudes in today's med schools. "We're now teaching students to analyze the information they're receiving. I think they are much better off now."



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