Contrary to the fears of some, competition from interventionalists who rely on imaging, endoscopy, and minimally invasive procedures isn't the end of surgery; it is the birth of a new, more competent surgeon.
   "I've been hearing about the death of cardiac surgery since the first angioplasty in 1977," said Lawrence Cohn, MD, professor of cardiac surgery at Harvard Medical School and senior surgeon at Brigham and Woman's Hospital in Boston. "It isn't going to happen. Vascular surgeons led the way and cardiac and other surgeons are following the path into the interventionalist lab. There will be competition and patients will benefit."
   The path to the future is already clear, Dr. Cohn said. Traditional cardiothoracic training is already expanding to include interventional and electrophysiology techniques. Current residents are already learning areas such as aortic stent grafting, percutaneous valve technology, and stenting of peripheral arteries. Practicing surgeons are taking three-month fellowships to learn the same techniques, then taking the new technologies and attitudes back to their home institutions.
   Practice boundaries are shifting, too. Brigham and Women's is creating hybrid service lines. Rather than surgery and medicine, a new Department of Cardiovascular Disease combines both. Look for other new entities such as a Department of Digestive Diseases or Thoraco-Vascular Diseases.
   Between May, 2003 and December, 2004, an elective hybrid therapy program gave Brigham and Women's patients a stent and a mini AVR in the same day. The STS mortality risk for a comparable patient population undergoing full sternotomy with CABG is 7%, but the hybrid group had 0% operative mortality and 0% reoperation for bleeding. The Cleveland Clinic and University of Pittsburgh have similar hybrid programs Dr. Cohn added.
    "You have to recognize that stents are simply better for some patients than a vein graft," he said. "The OR of the future is effectively going to combine a cath lab and OR to ease procedures and improve patient outcomes. You have to recognize that you can do the same job with smaller incisions and that is to the patient's benefit. What you can't do is practice like you have been for the last 20 years."
   Oncologic surgeons have already learned the lesson, said Mahmood Razivi, MD, director of clinical trials at St. Joseph's Vascular Center in Southern California. Using imaging to guide more traditional therapy is becoming part of mainstream medical practice.
    "Why would you want the risk of systemic exposure to a chemotherapeutic agent if you can offer intra-arterial treatment by injecting your agent directly into the tumor?" he asked. "Even in areas where an absolute survival advantage for the new technology has not been shown, quality of life advantages are clear."
   Focused ultrasound, laser ablation, and other technologies are becoming treatments of choice instead of "Hail Mary" options for patients who have failed other treatments or are unable to withstand traditional therapy.
    "This is the wave of the future," said Julie Ann Freischlag, MD, head of surgery at Johns Hopkins. "New surgeons want to learn how to do this. We are changing training, making it disease-focused. Surgeons are hands-on people. They want to diagnose, image, treat, stay with their patients all the way through."
   Hopkins' current surgical residents don't just learn to operate. They learn open procedures, minimally invasive procedures, imaging, ultrasound, and research, essentially every aspect of diagnosis and treatment of particular disease classes.
   A new hospital building reflects the new focus with organization by disease. The cardiovascular floor combines cath lab, OR, imaging, and cardiology in a single area. GI disease has its own floor. So do neurology and pediatric care.
   "We are training with a disease base," Dr. Freischlag said. "The key for surgery is to be ready for the future. The new generation is really ready for that."
   Michael Silva, MD, is moving older surgeons along the same path. As chair of vascular surgery at the Cleveland Clinic, Dr. Silva is designing training structures to bring new technological skills to experienced practitioners.
   "Surgeons already have a dedication to training," he explained. "There is widespread agreement that we should have all the tools available to take care of all of our patients and their complications."
   The current solution is a series of three-month Senior Emerging Technology Fellowships. The five programs, offered by Texas Tech, Cleveland Clinic, Northwestern University, Kaiser Permanente Hawaii, and Baylor University, are designed to transfer new technological skills to highly trained and experienced surgeons.
    "The most objective people in the world are those who can do both old and new technologies well," Dr. Silva said. "Endovascular skills are a new area, but compared to open surgical skills, they are relatively easy to learn."