Copyright © 2007 by Regina E. Herzlinger. Click here for terms of use.
The decline in the need for hospitals has been driven partially by a relentless flow of technological innovations. Some of the innovations are so complex that their innovators have won a Nobel Prize, such as that awarded for developing the process that automates the replication of DNA. But among the most important innovations is the simplest—a catheter, a plastic tube.
In the late 1960s, President Lyndon Johnson pulled up his shirt to display the scar left on his ample belly from a gallbladder operation. President Johnson was as justly proud of his scar as the other survivors of the grueling surgical procedures of that time. Perhaps you have heard your elderly relatives' vivid and lengthy recollections of their own operations.
Most surgery is performed to remove a diseased, unnatural, or debilitated part of the body—an inflamed appendix, a malfunctioning kidney, the stretched-out part of a blood vessel, or the calcified section of a joint. Sometimes its purpose is to insert a replacement part—an artificial hip, a new heart valve, an elastic tube or piece of a blood vessel, or, as in Jack Morgan's case, a new organ.
Why were these operations so traumatic? Because clever Mother Nature designed our bodies to foil invaders. To protect us from disease-carrying injuries, she buried key parts of our anatomy; covered them with a sturdy sheath of skin, muscle, connective tissue, and bone; and cushioned them with a layer of fat. She even installed an alarm system, made up of our nerves, that triggers a pain signal whenever the security of this protective sheath is breached.
Mother Nature does not take kindly to violations of her defenses. When deft inventors developed anesthetics to knock out the body's alarm system, Mother Nature retaliated: early anesthetics induced virulent responses, including acute nausea. She punished patients who permitted surgeons to probe inside their bodies with daunting mementos: trauma to surrounding tissues, infections of the open cavities, and ugly scars. Those who endured operations thus learned painfully that it is not nice to fool with Mother Nature.
No wonder President Johnson was so proud of his scar. The removal of a gallbladder was a big deal in those days, and it cost a lot of money. In 1984, a surgeon charged $1, 000 for a gallbladder operation, to which the hospital would likely add $2, 000 to $4, 000 for the use of the operating theater and a semiprivate room.73The resulting expenditure of up to $5, 000 equaled about a fourth of the median income of American households in that year.74Surgery was not only expensive; it required lengthy hospital stays that busy and burdened consumers found increasingly difficult to manage.
People were once forced to endure traumatic and expensive surgeries or face death, functional impairment, or unbearable pain. But recent technological innovations dramatically changed all that, greatly reducing the trauma of surgery, the time needed for recuperation, and its cost.
The key innovation came from an unexpected source—the plastics industry.
Plastics revolutionized surgery through small plastic rods that are inserted through catheters (tubes) into natural openings in the body—such as the mouth, penis, vagina, and nose—or into small holes punched into the body. These rods are fiber optic light sources that illuminate the surgical site for miniature cameras (endoscopes) and small surgical instruments. They too are inserted through catheters. When these lights and cameras reach the surgical site, the surgeon can spring into action, using small instruments to operate, while watching an image of the surgical site on a screen.
The plastic tubes that enabled these minimally invasive surgeries were as revolutionary as the canals that ushered in the Industrial Revolution.
Other technological innovations also helped to reduce the trauma and costs of surgery. Computer technology automated not only the tiny camera sent down the catheter but many other devices that can diagnose or monitor the body's functioning without violently breaching its defenses.
New diagnostic instruments produce clear, crisp pictures of the soft tissue buried deep within the body that once could be seen only during exploratory surgery. Powerful computers reconstruct the information produced by the different forms of energy sent into the body to diagnose its contents. Sonar instruments can distinguish a malignant tumor from a harmless growth, a healthy embryo from a malformed one. CAT (pronounced cat, an abbreviation for computerized axial tomography) scanners use X rays to detect subtle differences in tissue densities. And magnetic resonance imagers (MRIs) use electromagnetism (or, more precisely, the interaction between external electromagnetic fields and those of the atomic nuclei of body tissues) to image tissues. Small chips and other electronic instruments power miniaturized monitoring devices, such as the noninvasive pulse-oximeters that can monitor the patient's blood oxygenation without puncturing the skin.
These computer-based devices have eliminated not only many exploratory surgeries but also some of the world's worst diagnostic procedures. For example, the late, unlamented pneumoencephalogram, used to detect masses growing in the brain, began with an injection of a gas into the patient's spine. The patient was then strapped into a chair and catapulted into various positions that caused the gas to flow into the normally fluid-filled cavities in the brain. The gas-filled cavities were then visualized. As one radiolo-gist put it, this procedure "almost inevitably resulted in the mother of all headaches." This ghastly diagnostic technique has been completely replaced by MRI and CT techniques.
New forms of surgery were made possible by fiber optics and computer-based and miniaturized instruments. Minimally invasive surgery (MIS) techniques rapidly supplanted many older invasive ("open") procedures. The pace of change was staggering. For example, 80 to 90 percent of all gallbladder removals are now performed laparoscopically.75
Because MIS procedures do not require long periods of recuperation, they are typically performed in sites other than the in-patient section of a hospital. Of the estimated 28 million surgeries in 2005, 63 percent were completed outside the hospital walls.76An increasing number of these out-of-the-hospital surgeries are conducted in doctors' offices or in freestanding facilities that are not affiliated with a hospital. In 2005 more than 17 million surgical procedures were performed in outpatient sites.77
Why has MIS diffused so quickly and widely? Because it has greatly reduced the trauma, cost, and recuperation time of surgery.
Its appeal can be clearly illustrated by comparing two procedures to unclog coronary arteries and enhance the flow of blood to the heart: the old open CABG procedure, described earlier, and an MIS one performed with a catheter.
With a catheter-based procedure, also used to improve blood flow through the coronary arteries, called coronary angioplasty (or percutaneous transluminal coronary angioplasty, that is, PTCA), a radiologist or cardiologist snakes a catheter through a tiny opening, made in the artery in the groin, up to the artery in the heart. Contrast media enable her to watch the catheter's progress through the vascular system to its destination. When the catheter reaches the gunked-up portion of the coronary artery, a collapsed balloon, cleverly furled along the catheter, is positioned so that it straddles the blocked-up section of the vessel. Poof —the balloon is then inflated to distend the artery at the plaque. It is then deflated and removed along with the catheter.
The total time required for an angioplasty ranges from one to two hours. It is typically performed in an outpatient facility—that is, outside the hospital walls—and requires only mild sedation and local anesthesia.
The cost differentials between CABGs, in the $60, 000s, and angioplasties are significant, if somewhat eroded by the reclogging of the artery that sometimes follows angioplasty and, less frequently, CABG procedures. (The reclogging requires additional procedures.)78But a 2003 study concluded that angioplasties cost less than CABGs and drugs and have better outcomes.79This cost differential is likely replicated for many other surgeries. After all, many MIS procedures require fewer resources than open ones: less time in the hospital, less time for recuperation, a smaller team of assistants, and even a cheaper outpatient setting for many procedures.
But lower costs are not the sole economic difference between the two types of surgeries. More important, MIS procedures, like angioplasties, enhance national productivity because they enable people to return to work more quickly.80For example, newly introduced MIS hip replacement surgery can be done on an outpatient basis. If performed in a hospital, it reduces the length of stay by more than half.81