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?
