In no other time in history has such a rapid transition to the future occurred. What had been a century of evolution from the Industrial Age to the Information Age has, over the past decade, become a revolution. Laparoscopic surgery, which provided the “wake-up call to the information age” as the leading edge technology, has become the accepted standard of medical practice; now even more advanced technologies promise further improvements in the practice of medicine.

Many authors have written about revolutionary times; however, there are revolutions and then there are revolutions. The first great revolution in medicine occurred in surgery in the late 1800s when the giants in medicine still strode the earth. Although many pioneers contributed to the final remodeling of medicine, there were few visionaries who truly understood the magnitude of change and were able to give birth to the new discipline of surgery. Among the more notable were Bilroth, Lister, Virchow, and Morton. This disparate group never worked together, but it was the spontaneous integration of their research and clinical skills that made modern surgery possible. It was the convergence of their visions and technologies over a short time that enabled surgery, not any single event. Bilroth brought the new skills and surgical instruments, Lister the asepsis, Virchow the pathology, and Moore the anesthesia. Without the synergy of all areas, modern surgery would not have occurred. Ancient myth, mysticism, and even some empirical fact over thousands of years of medicine had proved that the sanctity of the human body was inviolate to the knife—that a patient could not be operated upon and survive. Yet the scientific tools of the Industrial Age enabled the impossible, and science gave birth to surgery. In a relatively short period the foundations of surgery were laid for the next generation of pioneers to lead—the clinicians who exploited the technologies and advanced the art of surgery.

There have been numerous startling discoveries since these early beginnings and many remarkable advances. These have been noteworthy in their own right, but none changed the entire foundation of medicine as did the inception of surgery. The understanding of shock, cardiopulmonary bypass and cardiac surgery, and transplantation have all had enormous impact on the practice of surgery, but they have fostered the development of a new niche, splintering off a new specialty without changing the fabric of medicine. Other new areas have been created, in infectious diseases and chemotherapy, yet these are evolutions of the ancient art of the pharmacopoeia.

It is interesting, but obvious, that the changes that led to the birth of surgery were contingent on the discoveries that ushered in the Industrial Age. And just as the Industrial Age is waning, so too is the golden age of surgery. The Industrial Age is being replaced by the Information Age, and conventional surgery is being replaced by a host of minimally invasive therapies and noninvasive procedures. Because we are currently in the middle of this transition, it is unclear now how the next generation of medicine and surgery will appear, although trends in the technologies are toward low-power, miniaturized, low-cost yet highly “intelligent” systems that eventually will transform surgery from minimally invasive into noninvasive procedures whose development will depend on the emerging Information Age technologies. This is not to say that surgeons will no longer perform open or minimally invasive surgical procedures in the future, but rather that “conventional” surgery will recede to a niche, and noninvasive procedures will predominate. Laparoscopic (or minimal access) surgery is not an end-point; rather, it is a transitional phase between the radical approach of “open” surgery and the emerging forms of noninvasive image-guided procedures. But it was the seminal event of laparoscopic surgery that triggered the wake-up call to the Information Age—the realization that a revolution is occurring and that physicians must extend their horizons to discover the direction toward the future.

In order to have a revolution, all facets of a discipline must be affected, not just a single specialty such as surgery. A revolution must also reflect the same changes that are occurring in other scientific areas and in society as a whole. It must be consistent with the global predictions that are proffered, such as The Third Wave of Alvin Toffler,<sup>19 Toffler A.   The Third Wave New York: Bantam (1991). 

Cliquez ici pour aller à la section Références</sup> MegaTrends of John Naisbitt,<sup>13 Naisbitt J.   MegaTrends Asia New York: Simon & Schuster (1997). 

Cliquez ici pour aller à la section Références</sup> and, most important, Being Digital of Nicholas Negroponte.<sup>14 Negroponte N.   Being Digital New York: Vintage Press (1996). 

Cliquez ici pour aller à la section Références</sup> The former two authors gave us a peek into the power and magnitude of the revolution, but it was Negroponte's concept of “bits instead of atoms” that completed the concept. He emphasized that what we did previously on a daily basis has required using actual physical objects (atoms); whereas the new technologies emphasize using information (bits) to accomplish the same task. His classic example is that up to and including the Industrial Age, information in documents and letters was mailed physically from point to point (sending atoms across the United States), whereas during the Information Age the same information is sent by fax (bits) at a much faster rate and at lower cost. In translating this to the medical world, I will refer to “information equivalents,” which are electronic or digital representations of real physical world objects or actions.

The magnitude of the importance of the Information Age for medicine was revealed during a National Science Foundation workshop on Medical Applications of Virtual Reality in 1994, where the question was asked, “How much of what a physician does on a daily basis is really information management?” If you use the most liberal interpretation, the answer is about 80% to 90%. For example, during laparoscopic surgery, the surgeon looks not at the actual organs but at the video monitor (electronic image or information equivalent of the organs). When surgery is complete and the patient is visited in the recovery room, the surgeon glances at the physiologic monitor for the blood pressure, pulse, and other vital signs (equivalent of sense of touch). The visit is recorded into the electronic or computer medical record (rather than being written on paper). Radiographs, CT scans, and other images are all becoming digital (instead of film, microscope slides), and our entire surgical education process is incorporating computer-aided instruction, multimedia, and even virtual reality for simulation and training. Laboratory experiments in telesurgery have converted our hand motions to electronic signals, such that when the surgeon's hand moves, the electronic signal (information) is sent to the tip of the instrument, and the scalpel cuts. By making this mental leap of interacting with information as a substitute for real-world objects, the physician gains the capability to do things not possible in the physical world. For example, by using Doppler ultrasound to display the false color images on a video monitor we have given surgeons the long dreamed-of capability to “see into the body with x-ray vision,” which in this case is ultrasound vision of actual blood flow. Although we usually view the images on a video monitor, Jonathan Prince<sup>2 Chinnock C. Holographic 3-D images float in free space : Laser Focus World (June 1995).  22-24

Cliquez ici pour aller à la section Références</sup> has created one of the first three-dimensional (3-D) true suspended holographic images (hologram) for anatomic visualization, and this will soon be a full 3-D representation of the human body. With the imaginative concept of information equivalents, the challenge is to discover in daily practice ways of enhancing capabilities for patient care.

The potential of this innovative approach to medicine can be best illustrated by the results of a “blue sky” brainstorming session in late 1995. This rudimentary idea is referred to as the “Doorway to the Future” and touches upon how information equivalents tie together the fabric of medicine. The session was inspired by the many technologies under investigation, and integrated them into a meaningful system of complementary technologies. The following scenario, based on advanced technologies currently under investigation in the laboratory, is used to illustrate how the future could be 20, 50, or perhaps 100 years from now.

A patient enters a physician's office, passing through a doorway, the frame of which contains many scanning devices, from CT scan to MRI to ultrasound to near infrared and others. These scanners record anatomic, physiologic, and biochemical (like the pulse oximeters) data. When the patient sits down next to the physician, a full 3-D holographic image appears suspended on the desktop—a visual integration of the information acquired just a minute before by the scanners. When the patient expresses a complaint of pain over the right flank, the physician can rotate the image, remove various layers, and query the representation of the patient's liver or kidney about the LDH, SGOT, alkaline phosphatase, serum creatinine, or other relevant information. This information and more is stored in each pixel of the patient's representative image (a “medical avatar”) such that the image of each structure and organ (such as the liver) stacks up into a “deep pixel” all the relevant information about the structure. Each pixel contains not only anatomic data but also biochemical, physiologic, and historical data, so that needed information can be found directly from the image without searching through volumes of written medical records or a prolonged computer database search. Should a problem or disease be discovered, the image can be used immediately for patient education, instantly explaining to the patient on their own avatar what the problem might be. If a surgical problem is discovered, this same image can be used by the surgeon for preoperative planning or imported into a surgical simulator to practice a variety of different approaches to a difficult surgical procedure that will be performed later. At the time of operation, the image can be fused with a video image and used for intraoperative navigation or to enhance precision, as in stereotactic surgery. During postoperative visits, a follow-up scan can be compared with the preoperative scan, and, using data fusion and digital subtraction techniques, the differences can be processed automatically for outcomes analysis. Because the avatar is an information object, it can be available and distributed (through telemedicine) at any time and to any place. Thus, this single concept of replacing the written medical record (including x-ray and other images) with the visual record of a medical avatar gives the entire spectrum of health care unprecedented continuity.

The time could not be more perfect, for we now have the right type of physician and health care provider to take advantage of this new technology. These are our younger generation who have grown up in the video/electronic era, and who are comfortable with the new technology. To them, the future is now, and it is all digital.