Monday, October 5, 2009

Pragmatic innovation

I was reading an interesting article this weekend from the New Yorker about the recent financial collapse. John Cassidy's piece makes the case that the subprime crisis and subsequent implosion was an inevitable consequence of how Wall Street is structured (lack of oversight, disproportionate emphasis on short term profits over long term stability, the "keeping up with the Jones's" mentality of the big investment banks). While discussing possible oversight and consumer protection proposals that would potentially ameliorate future credit crises, this paragraph jumped out at me:
The Administration has also proposed setting up a Consumer Financial Protection Agency, to guard individuals against predatory behavior on the part of banks and other financial firms, but its remit won’t extend to vetting complex securities—like those notorious collateralized debt obligations—that Wall Street firms trade among themselves. Limiting the development of those securities would stifle innovation, the financial industry contends. But that’s precisely the point. “The goal is not to have the most advanced financial system, but a financial system that is reasonably advanced but robust,” Viral V. Acharya and Matthew Richardson, two economists at N.Y.U.’s Stern School of Business, wrote in a recent paper. “That’s no different from what we seek in other areas of human activity. We don’t use the most advanced aircraft to move millions of people around the world. We use reasonably advanced aircrafts whose designs have proved to be reliable.”

The parallels to pharmaceutical/medical device innovation are clear. Do we really need multi-million dollar Da Vinci robots and "incisionless" surgical advances when standard laparoscopy already provides the benefits of minimally invasive, same day surgery? Do we really need the latest combo-hybrid hypertension/cholesterol/diabetes pill when we have older, cheaper, just as effective medicines (whose patents have expired and aren't profitable anymore)? Does the American system of health have to be the most advanced, the most innovative, no matter the cost?

A more pragmatic approach is needed. Innovation and private enterprise have undeniably made our health care system what it is. But a system too dependent on profit margins and the "latest new thingy" is doomed to financial ruin. Laparoscopic cholecystectomy sets a high bar in terms of patient satisfaction and efficacy. Let's stop wasting American ingenuity and capital on making all too subtle, incremental advances (tiny belly button scar to an unseen scar on your vagina) and start focusing on those diseases where quantum leaps in treatments and outcomes are still possible (cancer, transplantation, diabetes, etc).....


Anonymous said...

Jeeze Buckeye,
Last weekend of the Baseball Season, College Football just gettin Revved Up, NFL teams sortin themselves out, and you're readin the NEW YORKER?!?!?!?!
Oh yeah, you live in Cleveland..."Wait till next Decade" Ohio...
And that Ohio State/Indiana game?? Talk about torture...
And whats so great about the New Yorker's cartoons anyway??


Jeffrey Parks MD FACS said...

Name a good sports magazine. SI is written for 14 year olds. Anyway, Cavs training camp started last week.

Anonymous said...

Good Point, Buckeye...I gave up on Sports Magazines back in the 90's.
EDSBS (Every Day Should be Saturday) is a pretty good College Football Blog if you can get past the Pro-Gator/anti Big 10 Bias...
I wish I could get excited about the NBA, I lose interest when the score gets into double digits...and lost interest when they went to the Breakaway Rims...


Anonymous said...

Drackman the Cavs will win the NBA title this year period. For the record, the Cleveland Browns won the championship in 1946,1947,1948, and 1949. No team has ever won 4 straight superbowls.

rrs said...

capitalism is great if your looking for constant innovation. still havent heard a logical explanation why banking falls into that category.

re: sports mags, check out this site,

Anonymous said...

In my area, Chicagoland, there has been a ramping up of marketing at all facilities. Much more than usual in the last 6 months. One in particular on the car radio the other day was totally a Da Vinci brag.

Anonymous said...

My medical office stats...

Sports Illustrated: is read by 14-18 yr old females only.

"O" (Oprah's magazine) and People: are read by 38-50 year old men only.


Anonymous said...

Buckeye is bang on- sports magazines ARE crap. Why?

Drackman: you're way out of line as usual and anyway, who gives a shit what you think. Cleveland rocks!!! (as does the New Yorker).

Joseph Sucher, MD FACS said...

Jiminy Cricket.. I guess I'm going to have to keep this boring and on track. While I suspect that I agree with the Buckeye on principle, I want to offer a counter-point. I am probably I'm just nitpicking again, but what the heck. Let's start with a quote from our favorite surgeon blogger (for reals).

"The parallels to pharmaceutical/medical device innovation are clear. Do we really need multi-million dollar Da Vinci robots and "incisionless" surgical advances when standard laparoscopy already provides the benefits of minimally invasive, same day surgery?"

Answer: Yes. How 'bout that.

We really do need to continue to advance the field of surgery (incrementally or otherwise). With your logic, we would not have laparoscopy. Maybe you missed the early years of your teachers lamenting the "stupidity" of laparoscopic surgery. You may (or may not) remember mini-cholecystectomy. This technique was performed through a 4-6 cm incision in the RUQ. When compared to laparoscopic cholecystectomy the recovery and outcomes are similar. More importantly, it was safer (back during the early bad years of lap-chole) AND it is most certainly cheaper. Oh.... but it has a bigger scar! Eeeck. In Buckeye's world this is not a reason to choose a more expensive surgical technique. Ergo, by your logic we should abandon laparoscopic cholecystectomy in favor of open mini-cholecystectomy.

Now, I must pause and pay my honest respects to Buckeye Surgeon. I know that he can beat me in any word war with his brain tied behind his back. But I will try to wrap up my thought process as quick as I can below.

NOTES and SILS are coming quite a bit faster than most of us are comfortable with. I think that there are benefits beyond the actual techniques themselves. That is; surgeons have been longing for improved ergonomic laparoscopic instrumentation. We struggle with less than optimal limitations in our degrees of freedom. For instance, if you watch an expert surgeon tie a knot with standard laparoscopic instrumentation you will see a true exercise in frustration. Take that same surgeon and give him robotic instrumentation with all the degrees of freedom and he/she will tie a knot as expeditiously as if the case were open. This is a good thing. Right now robotics are impractical for most "standard" laparoscopic cases. But that will change. But it will only change incrementally and with ongoing industry funding in the technology.

Let me end with a quote from a recent Buckeye blog posting:

"But before we demonize the healthcare sector as just an expensive, bloated monstrosity, perhaps we ought to make sure there's a safety net to catch those end up losing jobs when we start shutting down surgicenters and outpatient radiology clinics and making it more difficult for the pharm industry to get new drugs approved...."

I don't consider SILS/NOTES subtle incremental advances. They are techniques that are generating improved instrumentation, and may result in a radical improvement in our ability to operate safer.

High Tech Surgeon

P.S. Just for fun I have dipped my pen into the blogosphere. For better or worse, I will aspire to make my blog as enjoyable as Buckeye Surgeon. Thank you Dr. Parks for your blog. It is the best written and most looked forward to blog in my reading list. Please know that I understand my blogging efforts are amateurish at best. I hope to improve over time.

Jeffrey Parks MD FACS said...

SILS is a different animal. The cost increase is negligible and its implementation requires a surgeon to use laparoscopic skills already acquired. I'm a proponent of SILS. Davinci robots costs MILLIONS of dollars. At some point in the future, when we're not on the verge of bankruptcy, it would be reasonable to pursue the feasibility of robotics/virtual surgery on a wide scale. But for now...let's keep doing what we do best.

And mini-cholecystectomy is an interesting point. But not many surgeons were comfortable with the technique and hence it failed to gain widespread popularity. Not everyone can work effectively in tight quarters. Not everyone had available assistants needed for retraction. Lap chole was quickly adopted by surgeons across the country within a year.

And stop being so damn self-deprecating! Good luck with the new blog.