The Impact of Technology on Surgery: The Future Is Unwritten

Mario Morino, MD


Annals of Surgery. 2018;268(5):709-711. 

In This Article

Quality Versus Quantity

In the first part of this editorial, I aimed at identifying the challenges related to the present and future relationship between industry and surgery. But, can we propose solutions?

Buxton[19] described the investigation of a surgical innovation that is being adopted in the context of technology assessment. He identified an initial point in the life of a given technology when the adoption is low and involves only a small number of surgeons. This period would give an opportunity for a formalized assessment. However, the following step is when the uptake of the technology suddenly increases involving a large number of adopters. This marks the point beyond which it is not possible to do a formal assessment. By this time, the technology is already, rightly or wrongly, destined for adoption. This is the point that defines Buxton law, which states "it is always too early (for rigorous evaluation) until, unfortunately, it is suddenly too late." This concept clearly underlines the crucial role of timing in the evaluation of a new technology in a society characterized by a continuous increase in the speed of communication and decision-making processes. Because the point at which a technological innovation evolves into a novel procedure might not be obvious at the time, prospective open registration of new procedures and early ethical approval are necessary. Evolution and evaluation can then occur simultaneously.

There is no doubt that industry needs to make profit, and profit arises from quantity. On the other hand, good surgical practice is related to quality. The complex relationship between quantity and quality in surgery was brilliantly described and analyzed in a previous European Surgical Association (ESA) Presidential lecture by Henri Bismuth stating: "…if the intention is to ensure the quality of care, is quality quantifiable? How can we measure it? Should we measure it?"[20]

The solution, in my opinion, is to strive for quality and correctly evaluate quantity or, in other words, to quantitatively evaluate quality. In this process, there are 2 keywords: Ethics and Evidence-Based Medicine (EBM). EBM is the only paradigm that guarantees a correct quantitative evaluation of clinical results, while the respect of strict ethical standards will guarantee quality in surgery.

As stated by Patel et al[13] "Much had been written about the value of industry–physician relationship in advancing innovation and improving care. Collaboration between industry and physicians may well be essential to innovation, but the extent of this relationship needs to be transparent, and easily ascertained to allow readers of these studies to assess how a COI could bias the study results and recommendations."

Nevertheless, the enclosure of a correctly completed COI declaration to a manuscript submission form is not sufficient; awareness of COI should represent a strong ethical commitment in everyday practice of every surgeon.

Therefore, to bring objective research practices into the operating theater will require changes in attitude by surgeons and by professional medical associations.

For surgeons, the culture of research and evaluation should be inculcated during training so that it becomes as embedded as the profession's emphasis on safety.[19] At the same time, professional medical associations should respect the same ethical standards in their relationship with companies and sponsors.

I strongly advocate that ESA should play a leading role in this process through the natural role of leadership of its members and, in a more ambitious strategy, through the creation of a working group devoted to Health Technology Assessment (HTA) in surgery.