EDITORIAL
Forecasting Innovation in Surgery Thomas M. Krummel, MD
“T
he abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon.” Thus, did Sir John Erichsen (the then “surgeon-extraordinay” to Queen Victoria) define the state of surgical care in 1873. Sustained innovation has led surgeons into all of these domains . . . and more. Although he was an expert in the day, he was profoundly wrong about the future of surgery; he could not have even imagined entire fields of cardiac surgery, transplantation, or laparoscopic surgery. So much for an expert opinion. Throughout the history of surgical care, progress is always about innovation, whether it is in diagnostics, supportive care, monitors, tools, devices, technologies, or surgical procedures. Throughout the decades, complete fields of surgery such as surgical procedures for peptic ulcer disease or pulmonary surgery for tuberculosis have been introduced, perfected, widely practiced . . . and then eliminated. Such is the ebb and flow of the work we do and the needs of the patients for whom we care. As we look at the current state of surgical care, we would do well to remember the observation of Dr Mark Ravitch in a conversation I had with him walking back to Montefiore Hospital in 1983. After bemoaning the misuse of the term “surgery,” Dr Ravitch commented, “Surgery is not a place or a procedure, but an intellectual discipline characterized by operative procedures but defined by an attitude of responsibility towards the care of the sick.” He went on to comment, “The closed (non-operative) reduction in casting of a fracture or the supportive care of pancreatitis should always remain the realm of a surgeon’s care.” In discussion, Dr Ravitch and I then concluded that that craft of ours, the surgical operation, consisted of “what we see” and “what we do.” Put another way, a surgical procedure represents an image and a manipulation. In the past, the image was a direct visual image with a direct 2-handed manipulation. Over time, we have improved our image with loupes, operative microscopes, and video images. We have added cryo, thermal, and radio-frequency energy. We have adopted staplers and implantable devices; urologists have even added extracorporeal shock wave lithotripsy, the surgical procedure without an incision. There is every reason to believe that those who proclaim today that surgical progress is “done” are doomed to repeat Sir John Erichsen’s example. The ongoing and indeed relentless process of innovation, like the tides, is irresistible. The term “innovation” has become a buzzword for our day. A Google search on April 14, 2014, returned 127 million results in 0.47 seconds when searching for the term “innovation.” Although prevalent and perhaps becoming even trite (who hasn’t seen a hospital ad touting “innovative care”), the term has become cheapened to infer merely tinkering around the edges. As we labor in an era of standardization, evidence-based medicine, results reporting, and occasionally regression to the mean, real innovation remains worthy of our energy and focus. In a special report titled “Has the Idea Machine Broken Down?” The Economist thoughtfully reviewed the current state of invention, innovation, and creativity.1 In the feature article “Quantifying Innovation in Surgery,” Darzi’s group from the Imperial College of London has thoughtfully attempted to study and quantify innovation in surgical care with the lead author Hughes-Hallett.2 Despite the essential need for innovation in surgical care, this concept has heretofore eluded careful study. In this important article, the authors have drawn on more than half a century of study in social science and industry where understandable metrics on the process of innovation have been accumulated. This now allows surgeons not only to plumb our history but, perhaps more importantly, also to develop some predictive capabilities! By exploiting our incredibly reliable desire to publish, the authors used a bibliometric analysis of peer-reviewed publications: indeed, this seems a reasonable surrogate for original patents when considering progress in clinical surgical care. The authors queried patent databases from more than 90 countries and scoured PubMed to extract publication data from the same period. The data were then normalized using total patent and
From the Department of Surgery, Stanford University School of Medicine, Stanford, CA. Disclosure: The author declares no conflicts of interest. Reprints: Thomas M. Krummel, MD, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Alway M121, Stanford, CA 94305. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-0212 DOI: 10.1097/SLA.0000000000000804
212 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 2, August 2014
publication counts. Subsequently, patents and then publications were clustered into defined areas of technological innovation as a measure of technology and innovation on a year-to-year basis. Not surprisingly, Dr Ravitch’s principle of “what we see” and “what we do” aligns nicely. Rapid growth in robot-assisted surgical procedures (a better image and a better manipulation combination) and image guidance is highly correlated with patent and publication rates. Sigmoid-shaped growth curves, followed by prolonged plateau phases, seem to be the norm. The authors then reference a well-characterized study of innovation popularized by Everett Rogers,3 who fundamentally outlines an anthropologic study of the spread of a new idea: the innovation, its dissemination through communication channels, the passage of time, and the surrounding social system. In aggregate, diffusion has been the process by which innovation is communicated and adopted. This gives rise to the now well-recognized adopter categories of “innovators,” “early adopters,” “early majority,” “late majority,” and “laggards.” In this regard, in addition to serving as metrics of innovation, both patents and publications act to enhance communication and thus the diffusion of innovation.
C 2014 Lippincott Williams & Wilkins
Annals of Surgery Editorial
The authors cite a number of studies applying such quantitative approaches to innovation analytics. In short, in many other fields, there is a high correlation between patents and publications as a harbinger of emerging key technologies. Other technologies, with flat growth and low correlation, have matured, perhaps even become commodities. Accordingly, the novel application of this methodology outlined in this report may hold value in prediction and perhaps assist in decision making for future research agendas. In summary, this important article establishes for the first time that publicly available patent and publication data not only identify but, to some extent, also forecast technological innovation in health care. The authors have mapped decades of our surgical history and as such have functioned as archeologists, anthropologists, and pioneers.
REFERENCES 1. Has the idea machine broken down? The Economist. January 12, 2013:21–24. 2. Hughes-Hallett A, Mayer EK, Marcus HJ, et al. Quantifying innovation in surgery. Ann Surg. 2014;260:205–211. 3. Rogers E. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.
www.annalsofsurgery.com | 213
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forecasting Innovation in Surgery Thomas M. Krummel, MD
“T
he abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon.” Thus, did Sir John Erichsen (the then “surgeon-extraordinay” to Queen Victoria) define the state of surgical care in 1873. Sustained innovation has led surgeons into all of these domains . . . and more. Although he was an expert in the day, he was profoundly wrong about the future of surgery; he could not have even imagined entire fields of cardiac surgery, transplantation, or laparoscopic surgery. So much for an expert opinion. Throughout the history of surgical care, progress is always about innovation, whether it is in diagnostics, supportive care, monitors, tools, devices, technologies, or surgical procedures. Throughout the decades, complete fields of surgery such as surgical procedures for peptic ulcer disease or pulmonary surgery for tuberculosis have been introduced, perfected, widely practiced . . . and then eliminated. Such is the ebb and flow of the work we do and the needs of the patients for whom we care. As we look at the current state of surgical care, we would do well to remember the observation of Dr Mark Ravitch in a conversation I had with him walking back to Montefiore Hospital in 1983. After bemoaning the misuse of the term “surgery,” Dr Ravitch commented, “Surgery is not a place or a procedure, but an intellectual discipline characterized by operative procedures but defined by an attitude of responsibility towards the care of the sick.” He went on to comment, “The closed (non-operative) reduction in casting of a fracture or the supportive care of pancreatitis should always remain the realm of a surgeon’s care.” In discussion, Dr Ravitch and I then concluded that that craft of ours, the surgical operation, consisted of “what we see” and “what we do.” Put another way, a surgical procedure represents an image and a manipulation. In the past, the image was a direct visual image with a direct 2-handed manipulation. Over time, we have improved our image with loupes, operative microscopes, and video images. We have added cryo, thermal, and radio-frequency energy. We have adopted staplers and implantable devices; urologists have even added extracorporeal shock wave lithotripsy, the surgical procedure without an incision. There is every reason to believe that those who proclaim today that surgical progress is “done” are doomed to repeat Sir John Erichsen’s example. The ongoing and indeed relentless process of innovation, like the tides, is irresistible. The term “innovation” has become a buzzword for our day. A Google search on April 14, 2014, returned 127 million results in 0.47 seconds when searching for the term “innovation.” Although prevalent and perhaps becoming even trite (who hasn’t seen a hospital ad touting “innovative care”), the term has become cheapened to infer merely tinkering around the edges. As we labor in an era of standardization, evidence-based medicine, results reporting, and occasionally regression to the mean, real innovation remains worthy of our energy and focus. In a special report titled “Has the Idea Machine Broken Down?” The Economist thoughtfully reviewed the current state of invention, innovation, and creativity.1 In the feature article “Quantifying Innovation in Surgery,” Darzi’s group from the Imperial College of London has thoughtfully attempted to study and quantify innovation in surgical care with the lead author Hughes-Hallett.2 Despite the essential need for innovation in surgical care, this concept has heretofore eluded careful study. In this important article, the authors have drawn on more than half a century of study in social science and industry where understandable metrics on the process of innovation have been accumulated. This now allows surgeons not only to plumb our history but, perhaps more importantly, also to develop some predictive capabilities! By exploiting our incredibly reliable desire to publish, the authors used a bibliometric analysis of peer-reviewed publications: indeed, this seems a reasonable surrogate for original patents when considering progress in clinical surgical care. The authors queried patent databases from more than 90 countries and scoured PubMed to extract publication data from the same period. The data were then normalized using total patent and
From the Department of Surgery, Stanford University School of Medicine, Stanford, CA. Disclosure: The author declares no conflicts of interest. Reprints: Thomas M. Krummel, MD, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Alway M121, Stanford, CA 94305. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26002-0212 DOI: 10.1097/SLA.0000000000000804
212 | www.annalsofsurgery.com
Annals of Surgery r Volume 260, Number 2, August 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 260, Number 2, August 2014
publication counts. Subsequently, patents and then publications were clustered into defined areas of technological innovation as a measure of technology and innovation on a year-to-year basis. Not surprisingly, Dr Ravitch’s principle of “what we see” and “what we do” aligns nicely. Rapid growth in robot-assisted surgical procedures (a better image and a better manipulation combination) and image guidance is highly correlated with patent and publication rates. Sigmoid-shaped growth curves, followed by prolonged plateau phases, seem to be the norm. The authors then reference a well-characterized study of innovation popularized by Everett Rogers,3 who fundamentally outlines an anthropologic study of the spread of a new idea: the innovation, its dissemination through communication channels, the passage of time, and the surrounding social system. In aggregate, diffusion has been the process by which innovation is communicated and adopted. This gives rise to the now well-recognized adopter categories of “innovators,” “early adopters,” “early majority,” “late majority,” and “laggards.” In this regard, in addition to serving as metrics of innovation, both patents and publications act to enhance communication and thus the diffusion of innovation.
C 2014 Lippincott Williams & Wilkins
Annals of Surgery Editorial
The authors cite a number of studies applying such quantitative approaches to innovation analytics. In short, in many other fields, there is a high correlation between patents and publications as a harbinger of emerging key technologies. Other technologies, with flat growth and low correlation, have matured, perhaps even become commodities. Accordingly, the novel application of this methodology outlined in this report may hold value in prediction and perhaps assist in decision making for future research agendas. In summary, this important article establishes for the first time that publicly available patent and publication data not only identify but, to some extent, also forecast technological innovation in health care. The authors have mapped decades of our surgical history and as such have functioned as archeologists, anthropologists, and pioneers.
REFERENCES 1. Has the idea machine broken down? The Economist. January 12, 2013:21–24. 2. Hughes-Hallett A, Mayer EK, Marcus HJ, et al. Quantifying innovation in surgery. Ann Surg. 2014;260:205–211. 3. Rogers E. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.
www.annalsofsurgery.com | 213
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
