The Ongoing Need for Innovation in Transplant Medicine and Surgery (2005)

Scientific progress principally moves disorders that used to be dealt with in a problem-solving mode towards a pattern-recognition mode. This facilitates decision making. Pattern recognition is replaced by rule-based regimes in the further time sequence of scientific progress. It is the subsequent consolidation and standardization of processes which allows a broader application. Only then a valid comparison and evaluation of the results will enable further progress and potentially a broader diffusion of information (1). We are living in a world of increasing change and turbulence. The phenomenon of acceleration has been based on multiple factors, such as an increased connectivity, globalization, new entrants into previously defined and presumably isolated markets, increasing patient (customer) power, frequent regulatory shifts, geopolitical shocks, rapid increases of computational power, accelerating capital flows and shrinking product life cycles. These global challenges also affect medicine and surgery. As a consequence, increased organizational dynamics in research and hospital management, subsequent organizational instabilities and growing competition or rivalry can meanwhile be noted in many situations in medical scenarios. Organizations, including academic hospitals can principally react on all these challenges and change forces with either optimization or innovation concepts. The optimal balance between both strategies is subtle and often hard to find. This decision making process has even been described as a process of mastering contradiction, particularly with respect to organizational structuring and style definition in management and team leadership. Should we primarily foster process optimization with focus on volumes and scale efficiencies, methodological replication, standardization, organizational diligence, alignment, rigid control and hierarchy or better stimulate innovation by allowing organizational agility, experimentation, imagination, stimulation of variety, diversity, self-organization and network formation? From both management and scientific perspectives, innovation can principally be differentiated into either sustaining or disruptive innovations. Sustaining innovations basically depict the standard pace of technological innovation. The term is derived from managerial business engineering. It is the improvement an industry usually creates as it introduces new and more-advanced products, particularly to serve the more sophisticated customers (or very complex patients) at the high-end of markets. With sustaining innovations we basically refine what we already have achieved. It is a form of optimization (2). Most scientific progress achieved in surgery is probably also best characterized as being derived from such incremental process optimization. In this sense, many surgical operations have been further optimized technically during the recent decades. New principles and variations which were introduced most often aimed primarily at the improvement of the surgical techniques efficiency, without changing the basic principle of therapeutic intervention. Disruptive (radical) innovations were primarily defined in very competitive economical scenarios, where cheaper, simpler or more convenient products and services suddenly meet the needs of less-demanding customers. Regularly, disruptive techniques were primarily underestimated by experts and leaders on the field. PCR techniques, e-commerce, desktop computers or digital recording techniques are good examples for disruptive innovations in technology. These innovations represent marked alterations of approaches. Disruptive innovations have caused some of the best companies to fall into crisis and correspondingly most currently successful new market company entrants are based on disruptive ideas (2). Correspondingly, multiple medical or surgical examples for disruptive innovations can also be found. Liver transplantation, minimal invasive surgery or angioplasties represent examples for disruptive innovations in surgery. When faced with a technological threat, organizations often respond with even greater reliance on the familiar technology. Minimally invasive surgery for example was primarily disregarded by leading surgeons because the technique could only address simple procedures. But it was rapidly improved to the point that even relatively complicated procedures can be done through small ports. Angioplasty is a further example for a disruptive technology in medicine. Both techniques have been addressed with much scepticism and critic from experts in the first phase. Indeed problems were encountered but the technology and skills have improved and meanwhile the far simpler techniques have rendered open or more invasive surgery unnecessary in many cases. Correspondingly, increased surgical aggression, for example in oncological surgery, can (as an isolated approach) probably only achieve further incremental optimization of therapeutic results. Any real break-through will come as a disruptive interdisciplinary strategy. The specific topic of innovation in surgery is further complicated by the fact, that the term “surgical innovation” is not clearly defined so far nor is it formally regulated by governing bodies, as is the development of new drugs and devices decades ago. There is no FDA for the surgeon and existing guidelines and regulations appear to be rather insufficient. Uncertainties and disagreements can be found among surgeons as to what an acceptable variation on an existing surgical technique is versus what is new or innovative technique that would warrant an ethical review and the patient's specific informed consent for an experimental procedure or a research study (3). Transplantation also is a typical high-end product of modern medicine. In transplantation medicine many outstanding examples of innovative concepts can be detected, which have stimulated research and in parallel contributed to clinical results in other branches of medicine. Innovation in transplantation continuously comes from multiple sides. On the other hand, many longstanding and unsolved problems of solid organ transplantation, such as the persistent organ shortage appear to be difficult to overcome with current concepts and meanwhile are prone for disruptive innovative solutions (4). Most of the important advances in the history of medicine and surgery were introduced through an unregulated, informal innovation process (5). In contrast to economic scenarios, where innovations are tested by customer driven market perceptions, the major task of the scientific community in medicine is to evaluate the efficacy of new technologies, medications and techniques (6). What is “new and innovative” is not always improved and what is the “latest” certainly is not by definition “the best” (7). Most innovations, from product or process refinements to more radical changes particularly occur when disparate concepts or disciplines are merged. Transplantation characteristically requires an interdisciplinary approach in diagnosis, indication setting and therapy. We have therefore organized the structure of our annual transplant symposium in Heidelberg primarily as a multidisciplinary meeting. It is regularly located in the historical Villa Bosch, the former residence of Nobel Price winner Carl Bosch (1874 – 1940). The villa is also meant to symbolize creative potential. With our meetings we hope to stimulate scientific research and the vital exchange of ideas and concepts in transplantation to motivate further innovations for the benefits of our transplant patients.