OPN talks to Richard Kerr, Chair of the Commission on the Future of Surgery, about the findings of the independent review
OPN:Tell us a little about your background and education and your current role at the Royal College of Surgeons?
RK:I have worked as a neurosurgeon in Oxford for the past 30 years. After medical school in London, I trained in general surgery before taking up neurosurgery. I have specialised latterly in skull base and vascular surgery, after a general career covering all aspects of cranial and spinal disease. My research has been directed towards vascular disease by jointly running the MRC-funded International Subarachnoid Aneurysm Trial, the results of which helped change the management of intra cranial aneurysms globally. I was elected President of the Society of British neurological Surgeons in 2014, having also been elected to the Council of the Royal College of Surgeons of England in 2013. I have most recently chaired the Commission on the Future of Surgery, an independent review set up by the Royal College of Surgeons, published in December 2018.
OPN: Tell us more about the Commission on the Future of Surgery, of which you are chair of, and what the report hopes to achieve?
RK: The aim of this independent review was to investigate the enormous potential advances that will transform surgery over the next 20 years.
After a year of evidence gathering, the experts on our panel published a report that suggests surgery could be transformed for millions of patients by a new wave of technologies – driven by changes in digital technology and our understanding of human biology – which in some cases are potentially only months away. Unlike many previous innovations, the forthcoming technologies are expected to effect every type of surgery, the way it is provided and the way we train surgeons.
The report highlights four areas of technological development that are likely to have the greatest impact on how surgical care is delivered in the next two decades. These include robot-assisted surgery and minimally-invasive surgery; imaging (including simulation, virtual, mixed and augmented reality); big data, genomics and artificial intelligence (AI); and specialised interventions such as developments in transplants and stem-cell therapies.
The report also makes a number of recommendations applicable to Government, healthcare regulators and the medical royal colleges to ensure the surgical community is able to adapt to coming changes and enable patients to fully benefit from advances.
OPN: What sort of evidence have you looked at within the Commission?
RK: During its evidence gathering, the Commission conducted an extensive literature review, collected more than 70 written contributions, held four days of oral evidence sessions and met with numerous stakeholders, including national health, education and regulatory bodies, individual researchers, innovators, start-ups, digital technology firms, educators, patient charities, patients, surgeons in training, clinical commissioners and managers. The complete list of evidence can be found online, visit https://futureofsurgery.rcseng.ac.uk/evidence
OPN: How do you see the future of surgery looking, especially within the field of orthopaedic surgery?
RK: Technologies such as surgical robots, AI, 3D printing and new imaging methods are already changing and will continue to change the way surgical care is delivered. An improved outcome for patients with personalization of therapies is the driver for major change. Developments in genomics could open new avenues for the prediction, prevention, and early diagnosis and treatment of disease. Unthinkable only a few years ago, this applies to orthopaedic conditions, as well as many others. Less invasive procedures carried out earlier with genomic prediction of outcome and complications.
Operating theatres are likely to look different, with greater integration of digital technologies. The space should become more flexible and dynamic, as equipment will be smaller and lighter. In the long-term, AI could be used to schedule procedures, request instruments and monitor the environment. Digital systems will also provide guidance to the operating team and show enhanced anatomical imaging.
One other exciting new technology that we highlight in the report that is being used for orthopaedic procedures is virtual reality (VR) surgical simulation. We give the example of Touch Surgery and also FundamentalVR©, a London-based company which has developed VR surgical simulations with haptic feedback. Their technology provides surgeons with the opportunity to learn, rehearse and practise surgical procedures within a safe and controllable space. Feedback about performance and accuracy is available immediately. It allows users to evaluate performance and will help improve and maintain their skill set.
OPN: Will the training of surgeons alter?
RK: Yes. The Commission suggests that content of the surgical training curriculum will need to change to reflect the likely future career of a surgeon. Training is going to have to incorporate knowledge of computing, engineering, molecular biology, data literacy and governance, leadership, team building and communication, and, of course, human factors. New technologies such as data analytics and VR will enhance training with high-fidelity patient-specific simulation and remote mentoring and proctoring.
Of course, entry requirements for medical school will need to reflect the diverse range of skills required and should encourage students from other backgrounds, such as engineering or computing, to enter medicine.
OPN: How could the technological advances improve patient experience?
RK:In the future, surgery will potentially prevent – and not just treat – illness. Patients can confidently expect surgery to become gradually less invasive, more accurate, have more predictable outcomes, faster recovery times and lower risk of harm.
What should never be lost is the current unique relationship between the patient and the surgical team. As technology allows greater access to information, that relationship will become ever more important so that the treatment path selected reflects the unique personal wishes of the patients and their families. Surgery is likely to increasingly focus on improving quality of life, as well as operating on well people with the aim of prevention.
OPN: What obstacles could companies face to achieve the possibilities in technologies such as surgical robots, artificial intelligence and 3D printing?
RK:In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence. Patient safety and public confidence are crucial; therefore, pathways need to be developed to assess digital devices and new treatments with compulsory registration of novel technologies and devices, using real-time data. A ‘one size fits all’ approach for randomised control trials or a national registry will not work for all innovations.
The surgical royal colleges could have a role in working with national regulators to support or oversee registries of innovations, and also help provide the governance framework to allow the safe uptake of innovations that improve quality of life.
OPN: Does the future look bright?
RK: This is a very exciting time to be involved in surgery, so yes, the future does look bright. The future of surgery will bring innovative technologies, enhanced understanding of disease and wider collaboration among experts and innovators to improve patient care. However, the partnership between patients and health professionals will remain always at the centre of the delivery of surgical care.
The Commission on the Future of Surgery
The Commission on the Future of Surgery was set up in October 2017 by the Royal College of Surgeons. It is an independent group of 14 experts, who were tasked with identifying likely advances in medicine and technology in the next twenty years, and their implications for patients, the surgical workforce and healthcare systems. For more information on the commission, please visit https://futureofsurgery.rcseng.ac.uk/commission