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Spring 2012

Field of Surgery Evolves as Advances Take Medicine in New Directions

Charles Brunicardi, M.D., is the chief of the General Surgery Group and vice chair for surgical services for the Department of Surgery at UCLA Medical Center, Santa Monica. In addition to expertise in gastrointestinal surgery and surgery of neuroendocrine tumors, Dr. Brunicardi conducts research on the evolving fields of translational genomic medicine and surgery - custom-tailoring care decisions based on the genetic profile of a patient's disease. He also is the editor-in-chief of the premier surgical text, Schwartz's Principles of Surgery.

What is the role of surgery in developing personalized medicine?
Surgeons play a critical role in this emerging field because they have access to the disease tissue. We envision that the tissues of patients will be placed in a biobank. The information we glean from those tissues will become part of databases to help us develop genomic profiles on the tissues we remove. This will assist us in guiding decisions about care. Using these profiles, we will be able to preventively remove at-risk tissues, as well as decide on surgical approaches. With this information, we can make more informed choices, for example, about such things as whether a cancer patient should get chemotherapy prior to surgery. The Holy Grail is what is known as targeted therapy. Whereas surgery would remove the tissues at risk, targeted therapy based on the genomic profile of a patient's cancer has the potential to cure the patient for the long term.

How has the field of surgery evolved over the years?
As a field, surgery is more collaborative now. Historically, surgery was based on a command-and-control, top-down leadership approach. Now, it's much more about using collective intellect. The multidisciplinary conference is an example, where we come together with other healthcare providers to decide what's best for the patient, as opposed to the surgeon alone saying what is going to happen. And there is a greater emphasis on measures to ensure safety and prevent surgical errors.

How about the surgery itself? What has changed and where do you see it headed?
When I was a new faculty member at UCLA in 1989, we were just learning how to do minimally invasive surgery, starting with laparoscopic removal of the gallbladder. Since then, this technique has spread throughout general surgery. Surgery has become a kinder and gentler craft, and it will continue moving in that direction. The use of robots in surgery is just in its infancy, but we are learning far more about how they can be employed to improve the quality of surgery. As that technology merges with molecular imaging, you can imagine the robot guiding the surgeon to do things like sparing nerves and determining the margins of the cancer. Advances in imaging also have made a huge difference. When I was a medical student, we didn't have CT scans or MRIs. The change has been remarkable.

What makes you most optimistic about the field's future?
What's most exciting is how brilliant the medical students are. They are accomplished in multiple areas, in music, athletics, as well as science. And they have grown up on computers, so they are using them in exciting ways - for everything from simulation to Web-based education. The future is bright because of the brilliance of these students.

You have been a proponent of leadershiptraining programs for medical students and residents. What makes for a strong leader in surgery?
The key to becoming a leader in surgery is creating a vision that your constituency can become part of fulfilling, and then having the willingness to lead, to learn and to resolve conflict. There are, of course, different styles of leadership. There is command and control, based on fear and intimidation, and then there's the collaborative style of leadership, in which you build self-esteem using a collective intellect. That's the one I favor.





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