Here Dr. Dillin discusses his project and the future of spine surgery.
Question: What are you currently working on with spine surgery?
Dr. William Dillin: My current project, from a patient management perspective, is creating a visual information system for management of patient safety in the OR that is functional on hand-held devices. [Author] Atul Gawande, MD, showed the surgical world the value of a checklist for managing patients in the operating room. If you think about the OR as being very complex with a proliferation of technology, we have a lot of systems to manage.
What we are interested in is creating a visual process that is transportable and malleable to iPads, and this centralized process would be distributed to the anesthesiologist, circulating nurse and surgeon. It really is the integration of work flow and the World Health Organization surgical safety checklist. Surgery proceeds in a linear direction in four phases: pre-induction, post-induction but pre-incision, intra-op and closure. Each one of these phases has its own information demands related to safety and work flow. I see the anesthesiologist, the circulating nurse and anesthesiologist as crucial players working together to create efficiency of work flow and to reduce error. We simply want to make sure that surgery moves in this continuum from beginning accurately and safely for our patients. Cardboard posters in the operating room with system reminders are not practical to all surgical processes. We need this transported to touch screen computer systems, allowing the mapping process to incorporate variables related to patient, surgeon, diagnosis, and technical management.
Q: What motivated you to create your own check system?
WD: I have always carried a checklist in my head but not on paper. ["The Checklist Manifesto"] by Dr. Gawande points out when managing complexity in a system, we need written checklists. My question is why not visual mapping as the checklist manager? Dr. Gawande demonstrated that checklists for patient safety in the operating room have demonstrated significant value. The initial motivation was for us to try to perform at the highest level and the secondary motivation is to perfect this visual information presentation system and make it available for other surgeons to utilize. It has to be transported from cardboard to a computerized system. That's the ultimate goal.
We have enough things to manage in the spine intervention world. Why not make things easy? If you could follow a system that reduces failure and promotes patient safety, why wouldn't you do it?
Q: How does your checklist differ from existing lists?
WD: The most important focus for me is using visual information, which allows you to understand things in a better way than just type written communication. Our ancestors painted stories in caves and didn't sure a lot of words. Visually we can literally "see things" and get perspective and understanding. Visuals can communicate information that is intuitively understood by people. Now with touch screens and wireless technology we have the potential to really evolve this kind of information. If you have a visual framework you are less likely to miss something in modifying your decisions or following a process.
Ultimately, I can envision a visual system that takes surgeons and patients through the full process of decision making and surgical management from the preoperative time zone, through the operative phase and into the postoperative state. This comes to the topic of patient-centered spine surgery. You are trying to manage all of the decisions and the practical execution of tasks efficiently and reduce error for the benefit of the patient. As choices proliferate, managing risk and benefit for individual patients rises in complexity. The goal is maximizing the value to the patient, hence patient-centered functionality.
Q: Where is spine surgery headed in the future?
WD: I think patient-centered spine surgery concept is going to become the dominant trend. It is going to be measuring the value of surgery and the value of intervention and who should and shouldn't be operated on. Sohail Mirza, MD, published a framework for surgical safety concentrating on patient characteristics, disease attributes and treatment factors ultimately effecting outcomes. What is intrinsic to a spine condition, what is intrinsic to a particular operation and what is intrinsically bundled in an individual patient are major determinants of the ultimate value. In a sense, surgeons will be analyzing far more sub-group variables to facilitate patient centered surgery decisions.
The issue of biologics, the role of where stem cells will appear in some kind of enhancement or repair process for degenerative disc disease is in its infancy and evolving. How regenerative medicine concepts will be applied to permanent neurologic injuries with intent to reverse damage is another exciting frontier being worked on by a lot of smart people.
I also have an interest in the tug of war between motion preservation surgery and motion elimination surgery. Where is the appropriate value for each of these based on clinical subgroups? We have a lot of technology and how we apply it to the biology for the ultimate value of patients is an ongoing discovery process.
If we think of ourselves as spine interventionalists, there is a continuum from minimally invasive to maximally invasive. Clearly, our goal is to be appropriately invasive when indicated. This concept continues to be re-shaped.
Our ability to utilize image guidance and create 3-D models will only enhance surgical accuracy, because during spinal interventions we aren't shielded from a full visualization of the anatomy.
Q: How do continuously improve as a spine surgeon?
WD: When you think of yourself in the education world, how do you approach continuing education that has value for you to translate into good patient care? I think in the world of spine we do two things: information services and technical services areas. If you are continuously reinvesting in information through effective continuing education, I see us re-establishing our information base on a daily, weekly, monthly and yearly protocol and then expanding it. We obtain knowledge to help us advise patients on the optimum choices for their particular condition. This is an ongoing refinement process.
In the technical world, I do a lot of cadaver surgery. My view is to try to do whatever procedures we do on patients on cadavers every year, from the most minimally invasive injection technique to the complex array of strategies applied to surgical anatomy. If a pilot needs to practice flying an airplane, we need to practice our spine interventions. Surgical simulation has great potential to take us beyond and enhance the cadaver surgery model. Can we use computer simulation to practice techniques of surgery in general, as a skill set promoter, but also to specifically integrate anatomy, surgical approaches and specific technical maneuvers common to spine interventions?
In the end, we must be prepared from an information and technical capacity to service our patients.