To the physicians and surgeons who read JAMA, it sounds strange to hear that ancillary medical personnel are now doing surgery solo without the burden of 9 to 12 years of medical school, internship, residency training, and fellowship training. But truth is stranger than fiction—according to an article in The Guardian, this is reality in the United Kingdom and it may be coming soon to an operating room near you. Would you be willing to go under the nurse’s knife?

Surgery is a manual task and the procedure itself can be taught to many people. During the past 2 decades I’ve taught ocular surgery to almost 200 ophthalmology residents and I’ve seen the full spectrum of surgical skill and dexterity. Even those at the very bottom of the bell curve, with the poorest hand-eye coordination, can be taught to do at least some procedures. I’m also convinced that I could teach a highly dexterous teenager to perform some of the tasks of ocular surgery, perhaps even better than the worst surgeons. But there is a difference: surgical judgment. Teaching surgical procedures is relatively easy compared to teaching surgical judgment, which tends to take years to develop even after receiving a decade’s worth of solid medical education.

Our society has deemed that to become a physician and surgeon, there are strict requirements. We must complete medical school, internship, and residency. We must also pass the United States Medical Licensing Exam Steps 1, 2, and 3. We must then pass other exams showing competency and we must continue to maintain our knowledge base every year for the entirety of our careers. If this is the path to being able to perform surgery, then should nurses be allowed to circumvent the process? Why not deregulate everything and let it be a free-for-all, putting the burden of finding a reputable “provider” on the patient?

We can now have a situation where a patient is seen solo by a nurse practitioner in the clinic, who then refers the patient to a nurse who performs surgery solo, assisted by operating room nurses, while anesthesia is given by a nurse anesthetist. There is no need for an actual physician or surgeon except, perhaps, to absorb the liability in case things go awry. I value the nurses who are an integral part of our health care team, but I would not want to be the patient in this scenario.

Medicine and surgery, particularly ophthalmology, attract some of the best and brightest university students who agree to undergo a decade of training to provide a public health benefit to society. Should the right to practice medicine and surgery come from education or via legislation? We must look beyond the apparent cost savings achieved by using lower-level “providers” and ask ourselves what we would want for our own family members.





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  • Robert Nasser

    Robert Nasser declares conflicts or relevant financial interests disclosure.

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    The question is not one of technical prowess, that is simply a teachable skill, but the mental requirement of knowing what to do. Moreover if there are any complications or unusual conditions encountered knowing what to do. Surgery is NOT just a technical exercise but a combination of intellect and technique. A quick technique course does not suffice.