the end of medicine

“My hope is that we end surgery.”

The doctor leans forward, matching my posture: elbows on knees, fist nested in his opposite palm, like a model of a ball-socket. On the low table between us sits Milton Bradley’s Operation, its plastic bones and red buzzer nose, for the moment, silent, as if to foreshadow the future state of noninvasive healthcare that we are imagining. 

It’s a strange sentiment for a surgeon. But not strange to anyone who knows Dr. Elad Levy–Chairman of the Department of Neurological Surgery at the University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences, Co-Director of the Gates Stroke Center and Cerebrovascular Surgery at Kaleida Health, Director of Endovascular Stroke Treatment and Research Medical Director of Neuroendovascular Services at Gates Vascular Institute, and a National Director of the American Board of Neurological Surgery. And it is not strange to anyone familiar with the culture of this place, the brain-shaped building at the northeast end of the Buffalo-Niagara Medical Campus.

photo by mark dellas

We sit in an open lounge near the entrance to the Jacobs Institute, a nonprofit incubator and accelerator focused on vascular disease treatment and technology. Occupying the fifth floor of the Gates Vascular Institute building, it connects Kaleida Health’s four floors of patient care and surgery below with the State University of New York at Buffalo’s Clinical and Translational Research Center above. The Institute feels more like a Silicon Valley startup than a medical facility–there are meeting “pods,” glass offices that frost at the touch of a button, a commissioned video art installation looping behind the reception desk, and a café complete with a full-size La Marzocco, Sportscenter, and Bloomberg News. Surgeons and researchers chat while espresso hisses. Technicians oversee massive 3D printers shaping human organs from new materials, micrometer-accurate replicas of valves and vessels. Biotech executives from across the continent shuffle in with conference lanyards and carry-on suitcases. The ostensible focus on “vascular care” is an understatement. The Institute’s real objective, as banners and stickers and whiteboards everywhere declare, is to bring about “The Future of Medicine.”

Only in these almost millenarian terms do Dr. Levy’s pronouncements make sense.

“Can we go from minimal to zero?” he asks. “I don’t want to be practicing medicine the way I was trained. If I do that–I’ve lost.”

When this surgeon speaks of the end of surgery–he means it. And his colleagues at the GVI take it very, very seriously.

Chicken wings, snow, and stroke care. For the medical world, these are the tentpoles of Buffalo’s reputation. The combination is no coincidence: nineteenth and early twentieth-century working class diets and sedentary winter lifestyles contributed to cases of stroke in Western New York high above the national average.

A stroke, or a “brain attack,” happens when an interruption of blood flow to the brain begins to cause cell death. It happens to more than one million Americans each year. Traditional approaches to stroke care focused on prevention–reducing risk factors like cholesterol and smoking–or rehabilitation for survivors. But if a person experiencing a stroke appeared at a hospital or emergency room, there were no answers. A nurse might wheel you into the hallway to wait it out, two million neurons going dark each minute.

In the late 1970s (about a decade after the invention of the chicken wing), a Buffalo doctor began to think there might be a better way. L. Nelson “Nick” Hopkins had studied at Nichols, Rutgers University, and Albany Medical College before returning to Buffalo to start in private practice at the Dent Neurological Institute. He developed a reputation as a renegade almost immediately, using impromptu and unproven tools and techniques to deliver emergency vascular care. In one early car crash case, he inserted a balloon into a patient’s cranial artery to stop catastrophic bleeding; in other cases, he experimented with catheters to access parts of the body that otherwise would have required maximally invasive surgery. Within his first decade of private practice, Hopkins’ reputation had gone global: medical residents hailing from England, India, and places in between crossed seas to study his renegade ways. Whether they stayed in Buffalo, returned home, or traveled elsewhere, these students were fiercely loyal to Hopkins, becoming a kind of missionary corps preaching heresies against the global medical establishment.

Hopkins’ experiments and prolific research began to come to a head in 1989 when he left private practice to chair the University at Buffalo Medical School’s Department of Neurosurgery. Here Dr. Hopkins set a challenge for himself, his students, and the entire medical community: If surgeons can stop heart attacks in progress, why can’t they do the same for the brain?

“We can and will,” Hopkins said.

“Renegade” was a kind term. By 2000, Hopkins and his students were “cowboys” and “pariahs.” They promoted their research and results aggressively, seeking to shift the paradigm on stroke care. Boos and jeers met their panels and lectures. Dr. Levy, who joined the UB team as one of Dr. Hopkins’ fellows in those years, remembers an audience member remarking after a talk that “If I had a tomato, I would have thrown it at you.”

As recently as 2015, lecturers at the world’s top medical schools were instructing future doctors that there were no interventions for stroke. But that year marked the culmination of decades of efforts by Hopkins and his acolytes. They had thrown out the cardiovascular textbook long before. They had documented thousands of case studies of successful stroke interventions using endovascular techniques–notably thrombectomy, removing blockages from cranial arteries to save stroke patients’ brains. It had taken fifteen years to gather the level-one reproducible data. They had reached their watershed moment–in 2015, researchers, peer reviewers, editors, and department chairs could no longer ignore the data. One by one, The New England Journal of Medicine and others published papers independently confirming what surgeons in Buffalo had known for years: endovascular intervention was the new standard of stroke care.

The Gates Vascular Institute had opened three years earlier, a $291-million project bringing together Kaleida Health and the University at Buffalo. The building, by CanonDesign’s Mehrdad Yazdani, embodied Dr. Hopkins’ theory of “collisions”: numerous, daily, chance interactions across practices and disciplines. It was this kind of specialist cross-pollination that decades prior had led Hopkins to apply theories of the heart to care of the brain. The Gates Vascular Institute does more than break down the traditional silos of hospitals and medical schools, though: it brings together science, patient care, and innovation in a single building, all aimed at reducing the time from idea to reality–or “i2R” in the parlance of the Jacobs Institute. Before the Gates Vascular Institute, if a doctor had a patient day, they weren’t in the lab; if they had to do lab work, they wouldn’t be seeing patients. Here, every clot removed from a Kaleida patient on the operating floors heads upstairs to the University’s labs for genetic and protein sequencing and analysis of risk factors. That data then heads back downstairs to the Jacobs Institute, where it may serve any number of studies or trials aimed at further innovating stroke care.

And this interconnectivity extends beyond the glass walls of the GVI into greater Buffalo. A new AI tool (developed at the Jacobs Institute) now gathers and processes all CT scans taken at any imaging facility in the region, analyzes them for signs of stroke, and flags concerning cases to Gates in the form of notifications on the surgeons’ smartwatches. This is an enormous leap forward in the speed from detection to prevention–literally saving lives, a few million neurons at a time.

This combination of clinical volume, research accessibility, and innovation culture has helped to attract top talent from around the world–like Dr. Jason Davies, who came to UB and Gates after studying at Stanford and the University of California at San Francisco, or Dr. Rosalind Lai, trained at Wellesley and Harvard Medical School. Now they pursue resesrch, launch companies, and mentor the next generation of talent, all from the GVI. On the lower floors, residents from Memphis, Palo Alto, and Karachi train on elective cases–many patients from Western New York, and many from around the world, who selected Buffalo out of just a handful of places with the tools and training to handle the rarest of neurovascular conditions. On the upper levels, visiting lecturers from Leeds and other top global universities present their latest research to students, residents, and fellows, continuing to build on a body of experiment and scholarship that started here.  

The Gates Vascular Institute is now the largest neurosurgical operation in the world.

Or, as Dr. Davies puts it, “this is the center of the neurovascular universe.”

Elad Levy woke to water–in his eyes, in his nose and mouth, running down the sides of his face. Light came next, yellow, blue, and green, as he blinked his eyes dry. And then voices. Young men, mostly. Some hysterical, giddy. Some low, insistent, concerned. Elad’s mind dialed down the din to background noise, like the lapping of the water on the wooden dock. He had heard three words, the words he had worked for. He focused on those to the exclusion of everything else.

You made it.

A freshman rowing recruit to Dartmouth College, Elad had caught the attention of Coach Larry Gluckman when he was rowing in the first varsity boat as a senior at Choate. Under Gluckman’s mentorship, Elad led his team to go undefeated in dual racing in his first season, the spring of 1990. That summer he made it his goal to qualify for the U.S. National Men’s 18 and Under Team. A latecomer to rowing, he had spent countless early mornings training on Lake Quonnipaug in Wallingford, and during the winter months had convinced a Choate janitor to open the gym for him so that he could fit in pre-dawn sessions on the ergometer before classes. This dedication had propelled him to Dartmouth and through a winning freshman season. But the U.S. National selection process proved a challenge unlike any he had faced. Two weeks out from the qualifying race, Elad woke with a realization: to achieve his goal, he would have to create the conditions such that the only possible outcome would be his selection.

This was a deceptively simple solution given the range of conditions that could determine the result: equipment, weather, teammates, and of course his competitors. But he focused on what he could control, or at least influence: his body and his mind. It cost him. In the final trial, Elad pushed himself to the point of blackout. He woke up a winner in a shower of his teammates’ emptied water bottles and went on to represent the United States in the Junior World Championships in France.

Born in Tiberias, Israel, August 29, 1972, Elad Levy remembers a small home where he lived with his parents and grandparents–three generations in six hundred square feet. When he was six his family emigrated–first to Italy, then to Molone, New York, a tiny town in Franklin County, closer to Montreal than even Plattsburgh or Lake Placid, where his father worked as an OB-GYN. It was both the model of his father and the memory of the tiny house in Tiberias, he says, that drove him through Choate, Dartmouth, and then George Washington University School of Medicine: He didn’t ever want to go back. The experience of rowing at Choate, at Dartmouth, and in the World Junior Championships equipped him with a keen attention to the subtly shifting boundaries of the possible, and a belief in his own ability to change those boundaries–through effort, will, and what he calls “microdecisions,” myriad tiny choices that “move the needle” on whatever moonshot has captured his imagination.

Perhaps rowing also left him with a lesson in the costs of success: He gave up the sport two years into medical school when he realized it was jeopardizing his studies. Dr. Levy went on to a surgical internship at the University of Pittsburgh and a fellowship in neurosurgery at the University at Buffalo, where his ambitions collided with the renegade visions of Dr. Nick Hopkins. Though he returned to Pittsburgh for his residency, his head and heart were in Buffalo. He made it back just in time to help lead the final, fifteen-year push to make thrombectomy the standard of care for stroke patients.

Dr. Levy succeeded Dr. Hopkins as Chair of the UB Medical School Neurosurgery Department in 2013. For more than a decade, he has approached the job as he did the U.S. National Team selection: by working to condition the environment such that success is the only option.

“My first action of the day, before my feet touch the floor, has to be something that moves the needle,” he says. It might be sending a personalized note to a potential fellow he’s courting, reading the latest research from a lab half a world away, or sending a message on LinkedIn to a biotech executive who ought to visit the Jacobs Institute.

The results speak to the power of microdecisions. The Gates Vascular Institute is not only the largest neurosurgical operation on the planet; it also remains the most advanced, and often the best option for the most precarious patients. In addition to emergency stroke care and routine vascular work–averaging ten elective cases a day–Gates also welcomes the rarest cases, such as that of a child suffering from moyamoya, a shrinking of the blood vessels in the brain, most associated with parts of Japan and Chernobyl, sites of massive radiation pollution.

On the hardware front, Gates was one of the first operations in the world to adopt 3D printing of medical imaging. In practice, this means that surgeons on the first four floors can send scans of patients’ actual organs and vessels upstairs to the Jacobs Institute, and in a matter of minutes receive 3D-printed replicas exact to the submillimeter. They can practice difficult operations on the models, leading to improved outcomes–while eliminating animal testing. This technology has positioned the Institute as an outsourcing partner for other academic and commercial labs. On an average day, the Gates team is running as many as forty clinical trials of cutting-edge devices from outside partners.

As an ambassador for Gates and Buffalo to the global medical community, Dr. Levy most recently served as the president for the Congress of Neurological Surgeons’ annual scientific meeting in Washington, D.C., where he brought characteristic ambition and focus to bear. (“This is going to be a fast and bumpy ride,” he told the event committee members, before revealing an ambition to break every record–in attendance, scientific abstracts submitted, and financial support. They achieved all three.) The conference featured live endovascular cases broadcast from Buffalo to the thousands of neurosurgeons in attendance.

But what’s next?

It’s not rhetorical–it’s the question that consumes Dr. Levy, the one that keeps him up at night.

“We’ve conquered stroke,” he says. Any further innovations will be “iterative,” like the temporary stroke prevention devices that researchers here developed for cardiovascular surgeons. This continued evolution is important–literally lifesaving–but the culture at Gates was built for achievements on an even grander scale. 

Up and down the ten floors of the GVI, from the University’s research labs to the Jacobs Institute to Kaleida’s operating rooms below, the consensus is that the future is brain-computer interface, or BCI. Elon Musk’s Neuralink is perhaps the public face of the technology, which promises to make the blind see, to make the deaf hear, to make patients with Parkinson’s or catastrophic injuries move again–miracles, by any definition–through computer chips implanted on the brain and connected to other parts of the body.

Neuralink won’t begin human trials until later in 2024 at the earliest. But the first human trials of BCI in the world already happened–here, in Buffalo.

The approach brings together Gates’ history in endovascular innovation with new, emerging disciplines, like artificial intelligence and epigenetics. Using the same catheter technology that enabled the thrombectomy decades ago, surgeons here are able to pass chips through blood vessels to reach the brain. Once placed, the chips learn as the patients think, registering the firing of the neurons below them. The first human trial included two patients in Buffalo, two at Mount Sinai in NewYork City, and three in Pittsburgh. While the results haven’t been published, Dr. Levy hinted that 2024 will see a second trial with “several dozen” patients experiencing spinal injury, stroke, or degenerative disease.

There are also implications for previously unimaginable early warnings based on genetic markers and other factors. “Perhaps you may be ‘destined’ to get Parkinson’s disease” because of your genetic makeup, Dr. Levy speculates. “Sure, you may be destined–today. But what about next year? What if we change this factor, or this?”

What he describes is perhaps only comprehensible against the scale of human history–a movement over millennia from rehabilitation to intervention to prevention, stopping disease and degeneration before they happen. It’s not just the end of surgery, but the end of medicine as we know it.

For Levy and others at the vanguard here in Buffalo, it will be a fast and bumpy ride.