Who is buying? Who is paying? Who is selling?... Problems with economic modeling of surgical innovation

With the rise of technology, new paradigms for describing innovation have been developed in the business literature.  Specifically, the concept of “disruptive innovation” as defined by Clayton Christensen has become particularly helpful and widely-applied.  Disruptive innovation describes an innovation which topples the industry leaders, causing a significant change in market share.  This innovation usually start in an emerging market, are often inferior to the existing options, but offer superiority in terms of price and access.    As a disruptive technology grows and improves, it eventually becomes a direct competitor to the standard of care, and soon surpasses it.

A fundamental issue arise when this paradigm is applied to surgical innovation.  The theory of disruptive innovation requires acceptance of a number of economic laws that are simply not applicable to surgery  One, that a buyer (patient) has the ability to choose between treatment options, and that these decisions are educated by cost, safety and effectiveness. If true, innovation’s successfulness would be based on the number of patients buying that procedure . However, most surgical diseases require prompt surgical intervention for cure, leaving little room for supply/demand and cost considerations to play any role in a patient’s decision making. Additionally, surgeons cannot present all treatment options (as defined by every possible permutation of each stage of procedure and peri-operative care).  Rather, as is necessary for surgical safety, a surgeon presents a single surgical plan which they have mastery of, and perhaps one alternative non-surgical option.  Therefore, while patients may choose which surgeon or health care system they present to, they do not choose the surgical procedure performed nor the surgical devices used.  While patients (via their insurers) provide payment for surgical services, this payment does not bear influence over adoption of new innovation- thereby breaking the rules of market adopting of new innovation.  One could argue that patients do have significant choice and power to exert financial influence over surgical innovation, but this is only true once and innovation is widely accepted.  For example, a patient may choose between open, laparoscopic or robotic cholecystectomy  but currently none of these are innovative; they are widely accepted standard treatments.   The long road from early innovation to standard of care treatment, is not driven by patient preference as innovations in early stages are not universally offered.  This is in stark comparison to innovations in non-medical field where all products are available to any customer anywhere, anytim.  It's also distinctly different than the medical field, where any FDA approved medication is directly  and widely advertised to consumers.

If surgical innovation isn’t driven by patient choice, what is it driven by?   The true market place for innovation is actually surgeons “selling” to other surgeons.  That is, an innovative product, procedure or system is pioneered by one “seller” surgeon, results are published in surgical journals and presented at surgical conferences where “buyer” surgeons may decide whether they plan to incorporate the new innovation into their practice .  This separation of surgical service provided (ie- patient/insurer pay surgeon for cholecystectomy) and surgical innovation adopted (ie- one surgeon “buys” and innovation from another after hearing compelling research that it is superior) disrupts theability of market force to drive innovation. Until a surgical practice is so widely accepted that patients have heard of it and seek out surgeons able to perform it, market forces are separate from innovation.

What is “disruptive innovation” in the surgical field, if the market-force-based definition cannot be applied?  The heart of disruptive innovation is an innovation that is cheaper and more available than alternatives, and requires less expertise and less resources to achieve similar outcomes.  The major shift from open to laparoscopic surgery , or laparoscopic to endoscopic surgery , may seem like a model of disruption, but it fails to meet the definition.  While laparoscopy is often more cost-effective than open surgery, it is not more available (especially in developing countries), and it requires higher levels of expertise and more resources;  the exact opposite of disruptive technology.  Similarly, robotic surgery compared to laparoscopic surgery requires additional training and more resources.   These all qualify as sustaining (not disruptive) technology as defined by incremental improvements of known procedure that improve patient care.  Sustaining technology improves patient care and outcomes, and my goal is not to undermine or minimize its important role.  However, disruptive technology causes profound changes in patient care that revolutionize care. 

If surgeons are both the buyers and sellers of innovation, what are the valued factors of an innovation that make it an attractive product?  Surgeons highly value improved patient outcomes, especially in the short term (such as decreased peri-op pain).  Additionally, surgeons value solutions that save time in the operating room (ex- laparoscopic fixation devices) and innovations that predict  post-operative prognosis and complications (ex- better staging, prediction or poor outcomes).  Innovations that surgeons would likely NOT adopt are those that increase access by reducing the level of training required to perform a procedure (ex- procedures that can be performed by ER doctor, IR doctor)

Share you thoughts!  What innovations would you adopt? Why?

How To Find A Great Idea

Some questions to get the creative juices flowing...

 How will this (this = any thing) be different when computer chips cost less than a penny?  Someday  (soon, if you believe in Moore's Law) computing power will be so cheap that processors are incorporated into everything around us. Including the OR.   How will an operating table be different?  Will it sense pressure points and automatically adjust to relieve them? How will operating lights be different?  Will they "see" the surgeon's hands and automatically adjust?  How will surgical drains be different?  What could a "Smart Drain" do? How will sewing an anastomosis be different? Will the suture auto-adjust to tightness? 

How can this problem be solved be done without an OR? The safest surgery is one that you don't have to do. That's also the cheapest surgery.  Surgeons don't like coming up with ideas to eliminate surgery, but we need to (believe me everyone else is... IR, hospitals, payors).  If we don't ask these questions, we cannot control the answers.   How could we do an appendectomy without an OR?  If we could induce controlled apoptosis, could the body naturally seal off and digest dead or infected tissue without systemic sepsis?  How could w edo a lysis of adhesions for SBO without an OR? Could we design an adhesiolytic that could be percutaneously injected into the peritoneum and break up surgical adhesions?    

How can we "hard-wire" safety into surgery?  How can technology decrease human error? Can we decrease thermal injuries in laparoscopy by having the camera "see" which instruments are in the field and only allow cautery to fire when they are visible?  What complications could be avoided if we had real-time monitoring?  If there is a bowel injury during laparoscopy, can we have a "nose" on our camera or instrument that senses a change in the intraperitoneal atmosphere?

Inspired?  Leave a comment or visit our forum for more discussion 

Cautery Monitoring

Could we decrease thermal injuries to bowel during laparoscopy if the camera could recognize whether the cautery insturment was present in the visual field or not, and only allow for the cautery to be activated if its in the visual field? 

I could see two ways of designing this 

Option one would be to design a new cautery device (hook, for instance) that has a light sensor on it.  The amount of light that it senses would be used to determine whether or not its in the camera's field (I'm assuming that laparoscopic cameras are calibrated to have their light align with their visual field)  The light sensor would regulate whether cautery can be activated.  If its in the dark, it's probably not on the operator's screen and it shouldn't be activated.  If its in the light, it's probably is the surgeon's field and is safe.  This system might require calibration to be accurate with sensing the limits of the camera, but it has the advantage of only requiring one new piece of technology (a new hook) 

Option two would be to have an in-line video processing unit that the camera plugs into, which analyzes the video in real time and identifies whether or not the cautery instrument is present on the screen.  This unit would communicate with a second unit (on the cautery) to give a GO or NO GO on whether its safe to fire.  This option requires more computing (ie a computer has to recognize what a hook cautery looks like) and requires two pieces (camera piece and cautery piece) that can communicate.  It has the added benefit of increase precision in identifying if the cautery is on the screen. 

Anyone else have thoughts?  Do you think hospitals would invest in a technology like this for patient safety? Are there any other safety mechanisms that we could "hard wire" in to make surgery safer? 

Safe Surgery

The best thing that we can do as surgeon innovators is make surgery safer. Maybe its a new monitoring device.  Maybe its findings complications sooner.  Maybe its finding new ways to avoid surgery altogether, because the safest surgery is no surgery.

I see ways to make surgery safer everywhere I look.

Let's stop thermal injuries during laparoscopy.  Let's design a laparoscope that recognizes whether cautery is in the field, and only allows cautery to fire under direct vision.

Let's stop enterotomies during re-do surgery.  Let's design an adhesiolytic chemical that dissolves the adhesions, that could be injected into the abdomen before we even open the skin.

Let's stop waiting for patients to "declare themselves" after surgery.  Let's have Smart Drains that do more than drain fluid; let's have drains that tell us there is pneumoperitoneum before the patient gets septic, and tells us there's a leak before the abscess forms.

I know there are answers out there.  I searched for a place to discuss problems like these and find answers, but there wasn't anywhere.  So I made a place. This is the The Surgeon Innovator. It's a place for surgeons who dream, who imagine, who wonder and who build.