Why haven’t surgeons been on the front line of public health?

Public health has often focused on prevention tools that impact an entire community or population. Before Henry Bigelow MD described the use of Ether in 1846 to mitigate pain during surgery or Joseph Lister MD discovered the value of sterile technique, surgical candidates were few. Even if one were convinced tolerate the pain of surgery, more than half would die from the risk of infection. For most of surgical history, the risk of intervention far outweighed potential benefit. Thus, the percent of the population undergoing surgery were few, and the surgeons role in public health limited.

More than a century later we are performing 230 million surgical procedures per year worldwide. Death from infection after surgery is nearly eliminated, pain minimized and we are performing some of our most challenging cases with greater ease. Consider the Whipple Procedure; among the most technically difficult and highest risk surgeries ever performed and the only curative treatment for pancreatic cancer. In the past it required three separate operations and left many patients dead on the operating room table. We can now perform it laparoscopically in a single operation through penny size incisions with less pain and faster recoveries. For many of our most common procedures, similar advances have evolved.

Now that the surgical population has increased, surgeons are becoming key stakeholders in public health debates. With proven and cost-effective surgical treatments now available, the task of making it accessible and appropriate remains. Consider that after adjustment for cancer stage and patient preference, black patients in America have significantly lower rates of surgical treatment than whites for lung, rectal, and breast cancer. Or that complex spinal surgeries for back pain have increased nearly ten fold this decade with limited proven benefit for patients. What forces are shaping these significant patterns of variation? Surgeon bias? Patient knowledge and perceptions? Cost-barriers? Access to surgeon? And how can we better understand the value of these procedures in the context of health care cost containment strategies and the need for surgical therapies in resource-poor countries around the world?

These questions are now at the front line of surgical research, and a whole new generation of surgeons trained in public health are rising. The number of surgeries is expected to increase as our population ages and our technologies and techniques improve. Now, more than ever, more surgeons are needed to embrace their role in the enterprise of improving the health of the public.

Andrew M. Ibrahim is the Doris Duke Research Fellow in the Department of Surgery at Johns Hopkins Hospital. He can be followed on Twitter @AndrewMIbrahim.

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