Editorial m

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Surg Endosc (2002) 16:733-734 DOI: 10.1007/x00464-002-0005-2 9 Springer-Verlag New York Inc. 2002 and Other Interventional Techniques

Disruptive visions Surgeon

responsibility during the era of change

Technology waits for no one. The accelerating advances in science and technology have resulted in unprecedented disruption in the practice of surgery. The medical profession is exceedingly circumspect, and thus is left behind when rapid change occurs. Figure 1 shows the progress over time of technology, business, society, and medicine in response to a hypothetical revolutionary discovery. The scientific community has exponential and sustained advancement. Business is not far behind, capitalizing on the new discoveries for profit. The new products are incorporated into society by peer pressure, media, advertising, and easy acceptability by the general public. The conservative medical establishment, however, lingers behind. The result is a widening gap between what is technologically possible and what is actually achieved. The business community picks up readily, but markets to the mass consumer more often than the healthcare community. In fairness, some effects of rapid change have entered the healthcare field. Managed care has revolutionized (or devastated) the way healthcare is provided. Laparoscopic surgery has challenged the very tenants of surgery. Biotechnology threatens to dispense with surgeons altogether. However, in reviewing the changes that occurred, it is possible detect the technologies that were beginning to emerge but that were ignored by the surgical community. Certainly, endoscopy was given to the gastroenterologists, laparoscopic surgery was denied and ignored by the academic surgical community, and endovascular procedures are trying to be reclaimed from the interventional radiologists and cardiologists. The question remains, where were the surgeons when these technologies were emerging? Certainly, they were not at the forefront. The mechanism by which disruptive technologies cause revolutionary change was originally described by Clayton Christensen [1] in his revolutionary book "The Innovator's Dilemma," in which case studies were performed to analyze and understand why great corporations fail and small businesses rise to replace them. There are a number of fundamental issues that are operative, however one of the main reasons is that established organizations (including corporations, businesses, and professions) are not aware that a new technology has the potential to replace them. The organization is too busy perfbrming the daily duty and trying to serve

the customer's (or patient's) demands with minor, incremental improvements and they miss the "big picture" of how an emerging technology will displace them. Thus, technology "scouting" and technology "harvesting" are essential activities for any established corporation or profession, in order to be aware of the potential radical change that a technology could bring, and to be ready to respond to the change or, otherwise to be left behind. There are a number of technologies that are in the laboratory and that have the potential to impact surgery as much or more than those of the past half century. Human cloning will soon emerge from off-shore research facilities that have not joined the responsible international community. Tissue engineering, bioartificial organs, and intelligent prostheses will change the practice of surgery (why try to repair a diseased organ when you can simply replace it with a new, patient-specific one?) and perhaps result in only a single procedure for each organ. Controlled cellular metabolism through molecular engineering or a new class of pharmaceuticals can bring about the replacement of anesthesia with suspended animation, resulting in surgery in a bloodless field. Longevity may finally yield to discoveries in cellular regulation of specific proteins, such as apoptosis gene or inhibition of telomerase. On an even smaller scale, nanotechnology promises patient specific drug delivery systems, which may or may not need a surgical approach. A new class of intelligent robotics will go beyond the current enhancement of human performance. And the human species is migrating to the new environment of microgravity in the space station (and then beyond) while still unaware of longterm effects or required countermeasures. These are a few of the areas that must come to the awareness of surgeons, for they shall all have a major impact on daily practice. Waiting until others have developed the technologies may result in relinquishing them by default. Citing the pressures of daily practice does not abrogate our responsibility to be informed and to be aware of the technologies and their rate of insertion. In the Industrial Age, it took 25 years or longer for a new technology to become mainstream. But this is the Information Age, and technology transition occurs more rapidly, sometimes in as little as 5 to 10 years. However, there is a process by which these technologies

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Fig. 2. "The Valley of Death" in funding and commercializing technology. Courtesy of H. Lee Buehannan, Assistant Secretary of the Navy (R&D), 1995.

Fig. 1. The discrepancy between technological change and other sectors.

migrate, from breadboard in the laboratory to final shrinkwrap product on the shelf. The basic science effort is usuaIIy funded by the government, and must be "handed ofF' to the commercial world. At about 5 years into a research project, there is the "valley of death," where the government funding stops but the commercial sector has not yet invested. This is at the same time the technology is going through FDA approval process (Fig. 2). If a promising technology is not brought to the attention of the medical or surgical community, it will wither. Thus, bringing these new discoveries to the attention of surgeons is both an opportunity and a responsibility that has not yet been seized. There are certain avenues that should be pursued in a conscientious fashion. There should be a concerted effort to recruit these revolutionary (and seemingly unrelated) technologies for presentation at conferences and workshops. The fact that they may not seem to be immediately relevant to today's practice should not deter bringing them to the awareness of all surgeons. There should be inclusion of these technologies during the residency training programs. The moral and ethical implications of the technologies and their impact on changing both the medical profession and society as a whole should be addressed by the surgical community. For too long, the surgical community has disregarded

what is occurring around it, and the result is that the community is either losing an innovation to another discipline, or, even worse the community is not bringing the technology to fruition for the benefit of patients. The intent of this series of articles, all prefaced with the title "Disruptive Visions," is to raise these issues to be vetted by the surgical community. There is an entirely new scientific revolution occurring: I have called this the BioIntelligence Age [2], which is the origin of these disruptive technologies. Rather than dismiss these technologies as mere fantasy or science fiction, it is appropriate to view their basic science roots and potential, and to judge them with a measured and critical eye. As Steven Spielberg is often quoted "There is no such a thing as science fiction, only scientific eventuality." References 1. Christensen C (2000) The innovator's dilemma. Harvard Business School Press: Cambridge, MA, USA 2. Satava R (2000) Innovative Technologies: the Information Age and the Biointelligence Age. Surg Endos 14:417-418

R. M. Satava Department of Surgery Yale University School of Medicine New Haven, CT 06510, USA