Times have changed. In today’s world most vascular procedures from head to toe, not to mention heart, have endo-vascular alternatives. As this nascent field evolves and expands, open surgical approaches are being partially replaced by these less invasive options, forcing "cutting surgeons" into either embracing new developments or slowly face extinction as their field of expertise shrinks. This in turn is blurring lines between specialties—vascular surgery, cardiology, radiology—which were formerly quite distinct. When I studied medicine two decades ago, I would not have predicted this development. Indeed no one would have.

Evolutionary change in medicine is neither new, nor altogether unusual. I recall a family acquaintance whom I met in the early 1970s, an anesthesiologist. My father told me that he used to be a tuberculosis specialist when he started out, "And a rather good one." With the disappearance of TB he had to find new work. "It was a shame, he was a damn good diagnostician," I recall my father saying. In a similar vein, in the early 1980s one of my neurosurgery professors used to regularly lament the disappearance of pneumoencephalography. He had spent years honing his skills in this now extinct, Stone Age procedure, which was notoriously brutal, and much feared by patients. And all this for images that yielded a small fraction of the information that CT and MRI provide with no invasion.

That’s the way it goes sometimes. The price of more effective, less invasive innovations can be derailment of brilliant medical careers. Evolution is not always gentle.

Advances in medical research are not the only impetus for radical change in specialties. Economic factors also play a major role, although they tend not to be the sole factor leading to change. Fields that provide higher income with less work tend to attract practitioners from associated specialties as well as bystanders. Nowhere is this more evident than in cosmetic procedures which used to be the domain of plastic surgery, but now attract ENT, oral surgery, ophthalmology, gynecology, dermatology, and for injections like BOTOX®, anyone with a medical degree. I was recently amused by an item in the Medical Board Action Report, a publication that lists sanctions imposed on errant physicians. A physician was listed for "performing a thigh lift on a patient and failing to inform her that he was an ENT."

In my own specialty of neurosurgery there has been a radical shift towards increasingly complex spine surgery, which formerly used to be in the domain of orthopaedics. Even though neurosurgeons are commonly thought of as "brain surgeons," they have always relied on spine surgery for a decent living. Advances in the understanding of degenerative spine pathology, along with more powerful and less invasive diagnostic tools (MRI instead of myelography), have combined with an explosion of new technology in surgical implants to create a revolution in spine surgery. As it so happens, these new procedures offer higher reimbursement, much higher than brain surgery, thus completing the attraction factor for neurosurgeons. Indeed, there has also been an equally high interest level from orthopaedics, which has seen an increase in fellowship-trained spine surgeons. Spine has moved from being a stepchild of both specialties in the ’50s and ’60s, undesirable and "low-class," to the most favored: truly a medical "Cinderella story," if there ever was one.

Currently an average private practice neurosurgeon has a case mix which is around 20 percent brain surgery, the rest being almost all spine. We are now also seeing the advent of neurosurgeons renouncing brain surgery privileges and becoming pure spine surgeons, another phenomenon unimaginable in the ’80s when I went to medical school. In fact it would have been considered outrageous and repugnant. But nowadays it is understood. It is not just the reimbursement factor that’s driving this phenomenon; it is also a reaction to the ER coverage crisis, and especially to the malpractice crisis that continues to afflict certain states in the Union. And so it goes. Yesterday’s abomination becomes today’s routine.

Mass migration towards Sleep Medicine, mostly by pulmonologists and neurologists, is yet another modern change. Sleep Medicine is a field that did not exist as a clinical entity when I was in school. According to a pulmonologist friend with whom I inquired, the factors driving a remarkable rise in this specialty are similar to the spine surgery issues I mentioned above; new understanding in sleep pathology, a massive increase in sleep disorders in relationship to our obesity epidemic, and new diagnostic capabilities. On the economic side, Sleep Medicine provides equal pay for less work; most certainly equal pay with less call. An average pulmonologist/intensivist burns out within approximately a decade or so. What better alternative than Sleep? For those who are more durable, they can have the best of both worlds simultaneously practicing pulmonology and Sleep.

Where does it all end? Nowhere of course. Evolution never stops.

We evolved from shamans and barber surgeons into science-based enlightenment healers. We face one certainty in our future: medicine will continue morphing indefinitely and unpredictably as it has in the past leaving the inattentive or unaware as casualties in its wake. Eventually the future generations will view us as crude and primitive, as we ourselves view our predecessors.

I recall a memorable scene from a Star Trek movie ("Star Trek the Voyage Home," Paramount Pictures, 1986). The spaceship, caught in a time warp had somehow found itself in the late 20^th century (what a coincidence!). When Mr. Chekov, one of the crew, suffered a head injury and epidural hematoma, he was taken to a "modern" neurosurgical operating room where they started prepping him for a craniotomy. In a dramatic rescue attempt Captain Kirk and Dr. McCoy infiltrated the hospital where he was kept. As they strolled the hallways and elevators looking for him, Dr. McCoy was totally outraged with what he saw and heard: "dialysis" and "chemotherapy" were being offered to patients. This was to him as much Stone Age medicine, as pneumoencephalography is to me. As the drama peaked they stormed the "modern" operating room and found Chekov on the table. The space doctor, horrified and disgusted with what was about to be done exclaimed, "Put away your butcher tools man!" While Captain Kirk shuffled the O.R. crew aside, Dr. McCoy placed a pager like device on the unfortunate patient’s forehead, which emitted a characteristically stellar sound. With the feckless neurosurgeon and his team looking on in astonishment, Chekov miraculously awoke within seconds and was oriented to all except his rank (he claimed he was Admiral). It was now time to whisk him off this horrific "medieval" establishment before the savages came after them.

Great fantasy? I don’t know about you, but I’d rather be here with my scalpel and drill, doing what I was well-trained to do, than in the imaginary future, which is likely to hold unimaginable challenges. As for those caught in the vortex of change right now, I wish them all the very best.

This article is reprinted from the Fall 2006 issue of the San Joaquin Physician. Dr. Senegor is a neurosurgeon in Stockton and is the editor of the San Joaquin Physician.