Journal of Pediatric Surgery 50 (2015) 5–14
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Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
APSA Presidential Address
Try again. Fail again. Fail better. Thomas M. Krummel ⁎ Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA Lucile Packard Children's Hospital, Palo Alto, CA, USA
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Article history: Received 13 September 2014 Accepted 6 October 2014 Key words: Pediatric surgery Innovation Failure
Members and Guests of APSA, colleagues and friends. I am deeply grateful for the privilege of serving as your 45th President. There are probably a hundred others in the audience equally or more deserving of this honor, and I fully understand the role of chance and good fortune in such awards. Again, my profound thanks. In its very generous introduction Dr. Albanese graciously omitted the many missteps, mistakes and flat out screw-ups that do not show up on one's CV; nonetheless they form an equally and perhaps more important component of a career, and the inspiration for this address. I feel very much like the proverbial “turtle on a fence post”; when you see one, you know that the turtle didn't get there on its own. As such, I owe deep debts of gratitude both professionally and personally to many, I will enumerate a few. Over a professional career of 40 years spanning five institutions, I am indebted to the students, residents, fellows and faculty at the Medical College of Wisconsin, the Medical College of Virginia, Children's Hospital
⁎ Corresponding author. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jpedsurg.2014.10.026 0022-3468/© 2015 Elsevier Inc. All rights reserved.
© 2015 Elsevier Inc. All rights reserved.
of Pittsburgh, Penn State and the Hershey Medical Center, and Stanford University and Packard Children's Hospital. Those countless interactions and friendships have all made an imprint. I am grateful for many lessons from professional colleagues and friends at APSA and broadly throughout the surgical organizations I've been privileged to serve. Finally to my patients and their families, I am grateful for your lessons and for your demonstration of courage. There's one guy who spans both the personal and professional— Arnold M. Salzberg, MD, HB and an early member of APSA. Arnie was an icon, a mentor, and a friend. I'm one of Arnold's 12 disciples who were inspired to pediatric surgery. Salzberg and the 12 disciples! Arnie's laughing up there someplace (Fig. 1). True story. I'm a junior resident on Pediatric Surgery at MCV in 1979. It had been a terrible week. We had fixed diaphragmatic hernias on two beautiful 4 kg babies and then sat around and watch them die. Nothing to do. The following week a young hotshot, Bob Bartlett, shows up and gives a research conference on a newfangled technology—ECMO. After the talk, Arnie rivets me with his gaze and says: “hey Krummel, how many more kids are we going to watch die before you do something?” With the full support of Dr. Salzberg and Dr. Lazar Greenfield we put together a ragtag ECMO team. Eighteen months into it we reported some real successes at the Surgical Section of the AAP. Arnie was quick to point out “Bartlett proved ECMO could be done, Krummel proved anybody could do it.” The AAP Surgical Section offers the Salzberg Award for Mentorship, there's a good reason for that. Next is that young hotshot Robert H. Bartlett—RHB (Fig. 2). Dr. Bartlett has been a role model and a friend for almost 35 years. He graciously hosted a very young and not very bright PG2 resident at the University of California, Irvine in 1980. I camped out in the NICU at the Children's Hospital of Orange County and tried to be a sponge. Learning from two patients on ECMO, Dr. Bartlett introduced me to the intersection of surgical science and engineering which has remained a foundation and a passion for the rest of my career.
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Fig. 1. Arnold M. Salzberg, MD.
While there are many I would specifically like to acknowledge two “big brothers', Michael R. Harrison, MD and Joseph P. Vacanti, MD (Fig. 3). The two of them created entire new fields—fetal intervention and tissue engineering—through thought and action, and at the beginning, single handedly. Fundamentally, they built things we never thought of, or acted on before. Each of them authored the definitive papers and textbooks. Both have been of enormous service to the field of Pediatric Surgery and the patients whom we serve. I count them amongst my closest friends. Each knows something about failure as well. John and Marian Waldhausen, shown here during Dr. Francis D. Moore's Waldhausen Lectureship, made a huge impact (Fig. 4). John was the founding Chair of the Department of Surgery at Penn State; he recruited me as Division Chief and little did I know he was quietly grooming me to succeed him as the Department Chair. He truly taught me the art and science of leading a department, priceless lessons for the journey West to a troubled Department of Surgery at Stanford in 1998. While in Silicon Valley I've been privileged to learn from two master physician inventors/innovators, Rodney Perkins and Tom Fogarty.
Fig. 2. Robert H. Bartlett, MD.
Between them they are singularly responsible for 50 successful medical technology startups. More than 10 million patients have been treated with their inventions. They epitomize the exploration of new therapies and the expectations of failure along the way. My parents, Jim and Helen, taught me everything about what is important, long before I went to school. They taught me that you don't need much to have a lot and that scarcity and necessity drive innovation. I am privileged to have two terrific brothers and one terrific sister. Finally I am blessed with an extraordinary family, my wife, Susie, and three spectacular children, all of whom are here. They all help me to keep it real and make everything worthwhile. These family foundations are a daily reminder of both my blessings and my responsibilities to others less fortunate. With them I believe everything is possible. Marrying Susie has been the best decision of my life. The most famous painting ever depicting a physician is this one executed by Sir Luke Fields (Fig. 5). Appropriately for all of us in APSA, it depicts a physician puzzling over a sick child. There are many interpretations of this painting: some see the light of dusk and despair, others see the light of dawn and hope. What do you see? Regardless of those interpretations no one can miss the look of care and concern for this child's problem. What was the state of surgical care at the time of the painting? If this child had an intussusception, appendicitis, or even an incarcerated hernia death was likely. Roughly at the same time, Sir John Ericksen, the then “surgeon-extraordinaire” to Queen Victoria, declared “The abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon”. Times have changed. Why? How? Throughout the history of surgery, progress is always about innovation whether in diagnostics, supportive care, monitors, tools, devices, technologies or surgical procedures but progress is inevitably also about failure. Often, to discover ‘what works’, one must plow through an awful lot of ‘what doesn't work’. Entire fields were created out of serial failures. Solid organ transplantation, surgery of the heart and great vessels and laparoscopy were all developed through a series of fits and starts, a series of mistakes and adaptations. The development of surgical devices such as staplers, cardiac valves and the pulse oximeter all painfully evolved after discovering what didn't work. It is these lessons of failure that inform subsequent success and indeed are essential. A brief word about the title. Samuel Beckett was an Irish playwright who was awarded the Nobel Prize in literature in 1969. A profound
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Fig. 3. Michael R. Harrison, MD and Joseph P. Vacanti, MD.
pessimist, he authored the play “Waiting for Godot”. In 1983, in a parody entitled Worstword Ho!, he penned the words, “Ever tried. Ever Failed. No matter. Try Again. Fail Again. Fail Better.” While his view was profoundly dark and pessimistic, mine is profoundly optimistic. An alternative for this talk occurred to me and that was “The F-Word”. I had some concerns that is might be difficult to ever reference a paper with such a title! In the hallway between the locker room and the operating room at Stanford Hospital is a picture of a famous 1895 train wreck at Paris, France at the Garemontparnasse terminal. I've never been sure whether it occupies its current position en route to the OR by accident, as a joke or as a warning. But it is a daily reminder of our responsibilities. I have four simple objectives in this address. 1. Systematically observe lessons of failure in surgery, athletics and medtech innovation 2. Draw “generalizeable knowledge” in failure as a gateway to success 3. Explore the role of what Louis Pasteur called “the prepared mind” 4. Review key megatrends to inform where we should—try again, fail again, fail better In preparation for this I've reviewed hundreds of presidential addresses, the topic is almost some sort of success. So it is with trepidation that we get started.
I first became aware of Robert E. Gross from on his picture (Fig. 6) on Arnold Salzberg's wall and his The Surgery of Infancy and Childhood textbook on his bookshelf. During the early days of ECMO I visited not only Dr. Bob Bartlett but David Collins and others and their offices similarly had the same Robert E. Gross picture and Robert E. Gross book. He was the first President of APSA, founding father of the field and made enormous contributions, in particular with the first ligation of the patent ductus arteriosus, but also with the development of aortic homografts and many broad and deep contributions to our field. What would Dr. Gross know about failure? It turns out, more than a little! He did not match in Surgery at the University of Minnesota (he neglected applications to the MGH and the Brigham). Having been denied a surgical internship, Dr. Gross decided to abandon surgery and he began a pathology residency with Dr. Bert Wolbach at the Brigham. Fortunately, after several years he switched back to a surgical career and the rest is history. In reviewing his career, Dr. W. Hardy Hendren and Judah Folkman commented about his unique perspective because he was “surrounded by the many problems in the Pathology Department”. He understood the complex anatomy not just of cardiovascular problems but across the spectrum of pediatric surgery pathology. When I got back from my ECMO barnstorming tour, I wrote Dr. Gross a letter and in it I observed that his picture and textbook were
Fig. 4. John and Marian Waldhausen.
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Fig. 5. The Doctor.
everywhere, that his pupils had made profound contributions and as such, his legacy was lifelong and now being passed on to me and other of a next generation. I thought nothing more of the correspondence. Two weeks later a letter arrived in my mailbox—the return address was Robert E. Gross, Brattleboro, Vermont (Fig. 7). Dr. Gross began, “it gave me much pleasure to have the warm and good note from you. I'm glad that my old residents tell some of the nice things that happened on my old service and omitted some of the troublesome time which I should have handled in a better manner.” He indeed knew something about problems, mistakes, and failures.
Fig. 6. Robert E. Gross, MD.
Famously Dr. Gross' textbook lacked a chapter on sacrococcygeal teratoma. The story has been recounted by Drs. W. Hardy Hendren and Bob Shamberger that a trainee came to Dr. Gross to ask “how do I manage sacrococcygeal teratoma?” Dr. Gross commented, “it's in the book!” The trainee replied, “Dr. Gross, it's not in the book!” Dr. Gross searched, discovered, indeed, the chapter had been omitted from the book and found the missing chapter manuscript behind the heater register in the office. A perhaps more noticeable oversight, was Dr. Gross' failure to listen to Helen Taussig's suggestion. Dr. Taussig noted that patients with tetralogy of Fallot invariably became much worse when their ductal murmur disappeared, indicating closure of the ductus and elimination of the systemic-topulmonary shunt. Dr. Taussig asked Dr. Gross whether it would be possible to “make a ductus” to sustain such patients. Dr. Gross dismissed the idea; of course he had made a career ligating patent ductus. Alfred Blaylock, however, didn't ignore the suggestion and then the rest is history (Fig. 8). But where did Alfred Blaylock's insight originate? Dr. Blaylock later reported, “while on the faculty at Vanderbilt in 1938…I became interested in pulmonary hypertension.…Might be possible to produce pulmonary hypertension by subclavian to pulmonary anastomosis. Much to our disappointment it failed” [1]. Blaylock thus knew not only that a systematic to pulmonary anastomosis was possible but in addition it would not produce pulmonary hypertension. The stage was set. We all remember Blaylock's successes, but how did he get there? William Longmire recounts William Blaylock's road to success thusly [2]. “I learned of Dr. Blaylock's desire to oxygenate the blood by some extrapulmonary means.…Tests were made injecting oxygen intravenously, by various methods, intraperitoneally, and directly into tissues. All of these methods seemed to be ineffective. Dr. Blaylock had seemed to me to be rather depressed for several weeks prior…I was quite aware of the fact that several major, what might be called “advanced,” operations which he had attempted had not been successful. Each failure seemed to have provoked an accumulated depressive emotional reaction. Finally, I must say my enthusiasm for the idea completely disintegrated when I saw the frail cyanotic infant in the oxygen tent on the East Ward of Harriet Lane.” The first case was successful, electrifying the world. And yet, as Mark Ravitch points out in the Papers of Alfred Blaylock [3] “The patient load was heavy, mortality at first was considerable, and at times…there would be a series of consecutive deaths hard to bear.”
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Fig. 7. Gross letter, pages 1 and 2.
We all remember Cameron Haight as the surgeon to first successfully ligate and divide a tracheal esophageal fistula and successfully perform a primary esophagoesophagostomy thus restoring esophageal
Fig. 8. Trailblazers.
continuity and yet, here are his unedited results of his first seven patients—one survived and in the 4 year period after the first successful case, the aggregated survival was 37% (courtesy of Ron Hirschl). It certainly puts our current ability to thoracoscopically perform the same operation in a very different light. Everyone in this audience knows Thomas Starzl, MD, PhD as an icon. He's a recipient of the Presidential Medal for the Advancement of Science, as well a Lasker Award, the street adjacent to the University of Pittsburgh's hospitals has been renamed Thomas E. Starzl Way. What most people forget are the dark days prior to success. As thoughtfully recounted in his autobiography “The Puzzle People” [4] Starzl comments in Chapter 9, titled “The failed liver transplant trials”, “A pall settled over the liver program, no more patients were entered for more than 3 years.” About this time Dr. Starzl developed hepatitis and was dismissed as Chair at the University of Colorado. Fortunately for him, and for the field, Dr. Henry Bahnson recruited Dr. Starzl to Pittsburgh, created an ideal working environment and resurrected Starzl's career and paved the way for successful liver transplantation. On a deeply personal level, here's a good example. Dr. Albanese was kind enough to comment on the early ECMO experience at MCV. Let me give you the real story. It's 1980, I'm a PG3 resident and we've completed sheep perfusion studies and a huge local chart review to identify patients with predicted 100% mortality. I was called to the newborn ICU for what was anticipated as our first patient, a beautiful 4 kg girl with meconium aspiration syndrome. As we wheeled the ECMO apparatus into the NICU, the patient arrested and required episodic CPR. Both attending physicians were unavailable, one out of town and the other with such bad poison ivy it was impossible to gown and glove. We had two ECMO techs, two dog lab technicians and one newborn ICU nurse (my wife, Susie). You don't see in this faraway picture but a close-up picture shows a right carotid and a left internal jugular cannula. Why?—I tore the right internal jugular vein trying to shove a chest tube cannula in just as CPR was re-instituted…blood was pouring out of the neck. I can't remember how I was even able to control the proximal vein but it was shredded. I figured I had nothing to lose in going to the other side. I got the venous cannula in, 8 days later she came off ECMO. We were lucky with six survivors in a row followed by three straight mortalities. Imagine if the order had been reversed.
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I happened to recount the story to Dr. Judson Randolph as our bike trip was taking us through Nashville in 2012. Dr. Randolph commented “You know, Tom, the Good Lord looks out for ne'er-do-wells, drunks and young surgeons!” All I could say was, Yes sir, Dr. Randolph, I really wasn't sure in which category he placed me, perhaps multiple. Failure in athletics is axiomatic. Every serious gym/track/field/pool/ stadium in the world has athletes forcing themselves to failure…and then beyond. In 1952, Roger Bannister was favored to win the 1500 meters at the Olympics in Helsinki. He finished a disappointing 4th. His comment: “I'd let the nation down”. Two years later, at the Iffley Road Track, he stunned the world with the 1st sub 4 minute mile: He was a medical student at the time. He commented later “Being defeated and feeling that I'd let people down is what led me to go on. I would not have run 3:59:6 if I'd won that gold medal” [5]. For those who dismiss athletic experiences as trivial, Bannister later commented: “Only in something like running can finality be achieved, the sort of finality that is almost perfection. But it is not the kind of perfection that leaves you with nothing to live for. You are not your own executioner because sport is not the main aim in life. Yet to achieve perfection in one thing, however small, makes it possible to face uncertainty in the more difficult problems in life.” Bannister went on to a distinguished career in Neurology, he authored the definitive textbook, Brain and Bannister's Clinical Neurology [6]. Dr. Albanese mentioned the cross country bike ride, it had its originals in failure. In 2007 I attempted to do the California death ride which is 129 miles with 5 monster mountain passes and a total of 15,000 ft (3 vertical miles) of climbing. I crashed, finished only 2 peaks on 70 miles, clearly I was poorly trained. Failure was predictable. In prepping for the Ride Across America (RAAM), I reflected on Bannister's experience, the need for better preparation including mental preparation. The 14 month plan with diligent effort and a first-rate coach who specialized not only in master athletes but also in mental preparation. In my first conversation with Coach Scott Saifer, he asked the question “What's the toughest distance of the RAAM?” He then answered his own question “The 8 inches between your ears”. During our last conversation before I set off on the ride his final comment was “When you think you're going to quit, remember the lessons of surgical training”. NASA has some experience with failure. They hate it, they never forget it, and they learn from it. During the APSA Board of Governor’s Retreat in January 2014, we came upon a 4 ft × 8 ft giant poster on the wall at the Johnson Space Center. It included pictures of each of the Apollo, Challenger and Columbia astronauts who died as a result of failure. The concept was put in slightly terms during an interview with Andy Grove, retired Intel CEO. I had proposed that he do a Fogarty Lectureship, and in the course of getting acquainted he asked me how and why I had come to Stanford. I told him of the epiphany I'd had when I decided I'd rather go to Stanford and fail then forever wonder what might have been. Andy then asked, “What are the key factors for success in Silicon Valley?”, I answered: intellectual capital, financial capital and flat hierarchy. He reminded me, “you missed one—risk capital, the same thing that brought you here!” Over 15 years, we've learned a great deal about failure in the Biodesign Innovation Program. Our stated goal is to teach the process of innovation and create the next generation of medical device inventors and leaders. Over a 15 year period we've had substantial success. • • • • • • • •
More than 750 invention disclosures/patents Multiple abstracts, posters, chapters, manuscripts Biodesign Textbook in its 2nd edition Real world funding success 32 startups; 810 jobs created 135 grads, 8 rookies Birthed 18 other Biodesign Programs worldwide More than 250,000 patients treated
That said, Biodesign has been replete with failure. The entire process of prototyping involves identifying what doesn't work and then moving on to what does.
Two specific cases are illustrative. Matt Callaghan was identified as one of the Top 10 Inventors by Popular Mechanics in 2010. His current iteration is the result of 4 years of sequential failures. James Wall, then a surgery resident but now a Pediatric Surgeon in my department, had a similar experience. James and his team observed an OR case of mine —14 year old patient with a pectus deformity. Preoperatively there was a 45 minute thrash to place an epidural catheter for intra- and post-op pain control. The epidural was ultimately abandoned. Any of you seen a failed epidural? While we pushed ahead with the case, the team observed the problem and was able to bring together both fresh eyes and a “prepared mind”. One of the engineers on the team made the observation, “In the Engineering world we would never think of pushing with in-line pressure to force through a substance and stop suddenly; we would engage with a screw!” An Ah Ha moment! The team prototyped FAST. Within a single day; they demonstrated the ability to engage spinal tissue from a local butcher, using a true-to-scale threaded screw from Ace Hardware. Concepts were refined, over time multiple prototypes were developed and final concept now 5 years later is approaching. This past spring Trinity College in Dublin developed an entire exhibit at their Science Center on the subject of failure—no surprise given that Samuel Beckett is a graduate of Trinity College, Dublin. On the wall beneath the catastrophic failure of a Formula One race car axle failure is the sign “Fail Fast and Cheap. Fail in a Way that Doesn't Kill You!” While this is a new iteration, as I've learned from ‘digging’, it actually echoes the three principles of Peter Palchinsky, a Russian engineer. Palchinsky was a capable mining and civil engineer who spent a great deal of time analyzing the failure of many massive Russian engineering projects. He evolved the following principles: [7] • Try new things, expecting some will fail • Make failure survivable—safe spaces and small steps • Know when and how you failed and learn For his outspoken criticism, he was executed. That's the problem with a Stalin as your Boss! Ultimately what Palchinsky articulated is a variation of Charles Darwin's observation on Evolutions of Species: “It is not the strongest of the species that survives nor the most intelligent, but rather the one that's most adaptable to change.” In summary, I believe objectives 1 and 2 have been well demonstrated. Success often begins with failure, it is routine across very different fields of surgery, athletics and medtech innovation. Failing well is actually the KEY to success. Fail fast, fail cheap and don't get killed, Adapt and learn in an almost Darwinian model. It's fair to say that mindset does matter. How and why did Gross, Haight, Blaylock and Starzl get it right and others not? It begs the perpetual question: “Why are some people so ‘lucky’?” We turn to objective 3 which is to explore Louis Pasteur's concept of “the prepared mind” Prepared minds have always had the greatest success in scientific discovery. Ambrose Pare at the siege of Turin was cut off from supplies to oil which was usually boiled to cauterize wounds. Given the lack of boiling oil he turned to gentle cleansing with soap and water with much improved results and changed the way we think about local wound care. LJM Daguerre first perfected the development of a photographic plate because of the accidental contamination of a cabinet with mercury. Alexander Fleming observed the bactericidal effects of a mold and ultimately identified penicillin. Charles Goodyear discovered that rubber contaminated with sulfur became a much useful compound and developed the process of vulcanization. Finally Percy Spencer noted that the chocolate bar in his pocket consistently melted when he was testing a magnetron. Most of us would have ignored the observation; he identified the heating properties of a magnetron and thus birthed the microwave technology that is present in all of our kitchens. Perhaps no one contributed more than Louis Pasteur. He settled once and for all the fallacy of spontaneous generation. He singularly demonstrated the ability to preserve beer, wine and milk in a process we now know as
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pasteurization. Pasteur saved the French silk industry by solving the riddle of parasite attacks on silkworm eggs and set the stage for “vaccination” in cholera, anthrax and rabies. Either he was the luckiest scientist in history or perhaps he knew something. In 1854 Pasteur was named Dean at the University of Lille and in his inaugural address he declared “In the field of observation, fortune favors only the prepared mind. He later said “Imagination should give wings to our thoughts but when we need decisive experimental proof, imagination must be check and documented by the factual results of the experience.” On top of that, Pasteur had the sagacity to seize on the unexpected result, and not ignore it. Louis Wolpert [8] put it this way “Scientific research is based not on chance but on highly focused thoughts. It is not by chance that it is always the great scientists who have the luck. We are all surrounded all our lives by innumerable ‘facts’ and ‘accidents’. The scientist's skill is to know which are important and how to interpret them.” How might we encourage that? Sometimes it's easier to study the loss of the prepared mind as a prelude to encouraging it. Jim Collins has built a career on the systematic study of organizational success and failure. His books, Built to Last [9] and Good to Great [10] are classics and he most recently authored a book How the Mighty Fall [11]. Jim is a lecturer at the Stanford Graduate School of Business on creativity and has added richness of thought to our Biodesign Program. In his most recent book he pursues a systematically study of the decline in high performing companies. He specifically calls out the loss of the prepared mind in this way. “When the rhetoric of success replaces penetrating understanding and insight (we understand why we do these specific things and under what conditions they would no longer work) decline will likely follow.” “Luck and chance play a role in many successful outcomes, and those who fail to acknowledge the role luck may have played in their own success—and thereby overestimate their own merit and capabilities—have succumbed to hubris.” There are two experts who have gotten it right and said so succinctly. Paul Lautebur [12], Nobel Laureate for his contribution to magnetic resonance imaging put it this way: “You can write the entire history of science in the last 50 years….in terms of papers rejected by Science and Nature.” Our own past president, Judah Folkman (Fig. 9) told me
Fig. 9. Judah Folkman, MD.
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during my Pediatric Surgery fellowship interviews “Tom, there are no experts on the future, just experts in the present” [13]. “Make sure you become an expert in the future.” I had the privilege of nominating Dr. Folkman for a Nobel Prize four specific times, the fourth nomination was sent just before his tragic and premature death. I'd like to think that perhaps, for him, the fourth would have been the charm. There's currently enormous focus on creativity, discovery, invention and innovation. These processes become an essential “skill” in a hyper-competitive world. A report in the Wall Street Journal on April 2, 2013 began to explore the best strategy when stuck on a hard or insoluble problem and how best to increase the likelihood of the “Ah Ha moment” [14]. In interviewing many who have had such moments there are consistent reports of what we now would call “the insight experience”. It always begins at an impasse and the insight frequently comes outside the active search whether in the shower, in daydreaming, or in active exercise. At the time it is often shockingly obvious and complete and there is an accompanying certainty to the concept. Whether it was Archimedes' gold crown composition and his Ah Ha moment in the bathtub, or Pasteur's insights in silkworm disease or Judah Folkman's tumor vessel puzzle or your current unsolved problem, it all begins with the impasse and frequently ends with a sudden insight not while laboring over the problem but by seeing it from another angle. What are conditions to enhance such insights? 1. When at an impasse, stop concentrating on details 2. Search more broadly and involve others. This functionally may represent a move from left cerebral hemisphere to the right. The opportunity to lose a focused consciousness and daydream, think about it in the shower or exercise seems to be a winning strategy. No one knows why. This observation was expanded in a research report in the Journal of Behavioral Psychology in a paper entitled “Give your ideas some legs: the positive effect of walking on creative thinking” [15]. Steve Jobs was well known for his walking meetings as is FaceBook's Mark Zuckerberg. Perhaps you've paced back and forth on occasion to drum up ideas. The study found that walking indoors or outdoors similarly boosted creativity inspiration. The act of walking itself and not the environment seem to be the main factor. Across the board creativity levels were consistently and significantly higher for those walking compared to those sitting. Other research has focused on how aerobic exercise generally protects against long term cognitive decline. This well-executed study demonstrated more and better ideas and positive effects on creative thinking and problem solving with activity: up to a 60% increase in creative output was measured and this appears to be sustained after the activity. Specifically, those problems that require a fresh perspective were consistently better solved. Does this work in the real world? The example of Minnesota Mining and Manufacturing otherwise known as 3M is a good example. Based on intellectual property filing, they are the third most innovative company in the world and the first to hardwire creativity policies. 3M has a specific policy entitled “the Flexible Attention Policy”. It encourages people to take a walk outside, play ping pong or engage in other playful activities. During such 15% time, your thinking and work MUST focus on speculative new ideas, such ideas must be shared with colleagues. 3M has a 75 year history of success as a for-profit company; these policies predate those of Google (which now has their own 20% role). The Post-it Note story is illustrative. Arthur Fry, an engineer in paper products, attended a Tech Forum during his 15% time. At the Forum an adhesives engineer presented a discovery—very weak glue—and asked if anyone had use for such stuff. Fry happened to sing in the church choir and the hymnal pages were frequently marked with scraps of paper which often fell out. Subsequently, Fry was daydreaming during the sermon and suddenly had the insight of a weak glue applied to a small piece of paper marking the hymnal pages and voila birthed the ubiquitous POST-IT NOTE.
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Finally, I'll try to address my thoughts on where we might focus our efforts as we “try again”. In his book Advice to a Young Scientist [16] Sir Peter Medawar suggested “It can be said with complete confidence that any scientist of any age who wants to make important discoveries must study important problems. Dull or piffling problems yield dull or piffling answers. It is not enough that a problem should be “interesting”—almost any problem is interesting if it is studied in sufficient depth.” One of our most literate and distinguished scientists, Medawar later wrote “The human mind treats a new idea the same way the body treats a strange protein; it rejects it”. Well here goes some new ideas. First and foremost I think the theme of this 2014 meeting has been “what direction is the field going.” Our four distinguished lecturers, Drs. Jacques Marescaux, Diana Farmer, Gail Besner and Eric Rose have added enormously to our understanding of lessons learned and options opened. The innovation panel entitled: “Where is ‘the puck going’ in the advancement of our field?” was designed to broaden our thinking beyond basic science investigation. Panel speakers Drs. Brad Rogers, Mike Harrison, David Powell, Gretchen Purcell Jackson, and Craig Albanese covered a broad range of talks suggesting a broad menu of areas to investigate. As we look on new approaches it is worth remembering out core competence. I was privileged to know Dr. Mark M. Ravitch during my time in Pittsburgh Children's Hospital in 1983–1985. Dr. Ravitch was an imposing, and indeed intimidating figure. Woe be it to the junior resident who spoke of taking the patient to “surgery” rather than “to the operating room”. Walking Dr. Ravitch back to his Montefiore hospital office was a unique privilege which I relished. It was a chance to see his incisive mind at work and his thinking has shaped mine to this day. I recall his thoughts about the definition of surgery as follows: “After all, Tom, ‘Surgery is not a place or procedure, but an intellectual discipline, characterized by operative procedures but defined by an attitude of responsibility toward the care of the sick’” [17]. So though we may solve problems differently as the years go by, it doesn't diminish us as surgeons. I would like to focus on four personally and highly selective megatrends. 1. 2. 3. 4.
Pediatric surgical workforce “Half the sky” Tools of the trade Ubiquitous computing
1. Workforce The number of board-certified pediatric surgeons has quadrupled from 1975 to 2013. The number of complex index cases is flat or diminished. There are many reasons including a historically low birth rate (1960-3.5/2010-1.89), selective terminations for malformation, and a relatively stable incidence of pediatric tumors. Shared concerns have bubbled up through the leadership of APSA, the American Board of Surgery [18], the American Board of Pediatric Surgery, the American Pediatric Surgical Training Program Directors meeting and the AAP Executive Committee. Specifically, we noted our new APSA member case logs are looking “thin” and recertification case logs indicate that the average Pediatric Surgeon performs 9.5 index cases per year, less than one a month. Past president Keith Oldham's Optimal Resource [19] work has focused on the attributes of facilities, we wanted to broaden to understand the attributes of our Pediatric Surgeons. Regrettably, there has been a price of de-regionalization. It has been well reported that in patients with pyloric stenosis, appendicitis, necrotizing enterocolitis that we have worse outcomes at low volume sites. This could be construed as either a problem or an opportunity but it certainly can't be ignored. Accordingly APSA has commissioned a Workforce Study in conjunction with the American College of Surgeons working with the Sheps Center at the University of North Carolina. Over the next year an exhaustive study of case volumes, demographics and practice patterns will be reviewed and workforce needs modeled for the next 15 years. This will, I believe, be a major theme for incoming President, Michael Klein. 2. Half the sky As I was preparing the Ternberg Lecture in 2011 I came upon a picture of the housestaff at Barnes Hospital in the mid 1950s (Jesse Ternberg as the only woman in a sea of men). I will compare that to the Stanford University Department of Surgery Chief Residents in 2010–2011 (five of six were women). We have come a long way. It was only in 1934 that Harvard Medical School went co-ed. The majority of medical students are now women. Women are no longer just pediatricians, they represent more than 20% of the practicing surgeons in the United States and as high as 40%
Fig. 10. Rigid and flexible scopes.
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at IRCAD. “The device as a procedure” has become more widespread. It is epitomized either in the Nova-Sure or BARRX device where RF energy is precisely applied and controlled not by the surgeon but by the device itself, thus a mucosal ablation is consistent and reliable and based on tissue resistance. No more over eager surgeon to overuse and no more timid surgeon to underdo—the device monitors and is tuned to tissue effects. 4. Ubiquitous computing
Fig. 11. Google glass contact lens.
of our surgical trainees are women. Such progress notwithstanding, there remain important and serious concerns about “the glass ceiling”. Additionally, progress in the United States is by no means reflected broadly worldwide. The Association of Women Surgeons Leadership Council's been an enormous force over the last two decades. During my last year as a Director of the American Board of Surgery we were able to change an old and arcane rule. Prior to that time, if a resident missed more than 4 weeks in any given training year, the entire year was discredited. Since the average maternity leave is 6 weeks, this functionally eliminated pregnancy during residency training as an option. What was informally known as “The Krummel Rule” allowed for flexibility for Training Program Directors and eliminated a ridiculous penalty for pregnancy. 3. Device trends In general we will see increasing complexity and thus increasing risk in medical/surgical devices. The risks, specifically, are technical due to complexity and expense due to development. I believe we will see merging platforms of rigid and flexible scopes and image guidance (Fig. 10) and we are very taking our lessons from Professor Marescaux
It's worth stepping back and remembering what has happened in the last decade. Tom Friedman put it this way: “Something really big happened in the world's wiring in the last decade but it was obscured by the financial crisis and post-9/11 era.” We went from a connected world to a hyper-connected world. I'm always struck that Facebook, Twitter, 5G iPhones, iPads, ubiquitous wireless and Web-enabled cellphones, the cloud, Big Data, cellphone apps and Skype did not exist a decade ago [20]. John Hennessey, president of Stanford University and member of the Board of Directors of both Google and Cisco made the following observation when he delivered the Fogarty Lecture. Professor Hennessey said: “There are two major trends in computing today—mobile and social. Nothing else matters” [21]. Ubiquitous computing has pulled the memory game off the table. We've gone far beyond Websites to smart tools, a hyper-connected medical system and a new definition of a patient. As Professor Marescaux has demonstrated, the massive, open, online course (MOOC) is embodied in WebSurg [22]. This has provided postgraduated education in minimal access surgery with 1.4 million viewers in 213 countries. There are now some 30,000 consumer facing apps on smart phones. Remote monitoring hubs and sensors are now available on Amazon. mHealth for physicians and professionals are ubiquitous, we're now approaching the next generation of wearable technology. In particular, I would like to focus on wearable visual computing currently embodied in the Google Glass®. The Air Force is now testing Google Glass® for battlefield use, coordination of resources and real time communication [23]. How might this be used in our field? What if it were possible for a trainee or a peer to actually see what the surgeon is seeing, perhaps with the addition of telestration or other coaching tools?” How does Dr. Shamberger approach a neuroblastoma, through his eyes-shared infinitely?
Fig. 12. New definition of patient.
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By way of summary, the lessons of surgical history, athletics and medtech innovation show that failure is a frequent gateway to success. It's not about avoiding failure, it's about failing well, which means failing fast, failing often and failing cheap but not getting killed. I hope I've suggested to you that the prepared mind is most likely to emerge with the best idea and have offered some strategies for how to facilitate that prepared mind. Finally, selected megatrends might direct your attention. I'll leave you with two thoughts. The attached cartoon “Early Experiments in Transportation” is insightful (Fig. 13). Indeed the wheel may be used for personal transportation but probably not in the manner depicted. But with the willingness to Try Again, Fail Again, Fail Better, Thor may eventually ride a bicycle or a Segway. One final thought: “The Art of Surgery is not yet perfect and advancements now unimaginable are still to come. May we have the wisdom to live with this with grace and humility.” As true today as it was when Halsted said it over 100 years ago. Again, my thanks and gratitude to the membership of APSA for the privilege of serving as your president. References
Fig. 13. Early experiments in transportation.
At the site linked below is a 90 second video watching what Roger Federer sees as he plays tennis. Anyone who has ever picked up a tennis racket will be stunned at the speed at which he plays (http://mashable. com/2014/05/21/roger-federer-google-glass/). For a surgeon in the operating room how might Google Glass® be augmentive? One could imagine the value of a heads up view of a checklist such as a WHO timeout, the possibility of looking up information in real time such as what is the dose of dantralene for malignant hyperthermia, it could be useful for video capture and distribution and it may allow real time communication between consultants and experts. It's not possible to show you a video of a surgeon but I can show you a food truck chef in what might be call “a kitchen operation” (http:// www.youtube.com/watch?v=H05At3ohbRE&feature=kp). Hard to know how this may play out, there will certainly be uses, successes and inevitable failures. For those that are concerned about the distraction of Google Glass®, there were similar concerns expressed about the use of headphones when the Sony Walkman was introduced some 30 years ago. And beyond that, is the theoretic possibility of providing images directly on a contact lens (Fig. 11). Today we tend to imagine the patient in the hospital. Tomorrow we can imagine a very different image (Fig. 12). Sensors, perhaps actuators and hyper-connectivity allow monitoring and perhaps care ANYWHERE. Shades of Andy Grove's “Shift Left” presentation.
[1] Blaylock A. CV Surgery Past & Present. NIH Lecture Series; 1963. [2] Longmire William. In: Ravitch Mark M, editor. The Papers of Alfred Blaylock, vol. I. Baltimore, MD: The Johns Hopkins Press; 1966. [3] Ravitch Mark M, editor. The Papers of Alfred Blaylock, vol. II. Baltimore, MD: The Johns Hopkins Press; 1966. [4] Starzl Thomas. The puzzle people: memoirs of a transplant surgeon. Pittsburgh, PA: University of Pittsburgh Press; 1992. [5] Reuters. Reported by Venetia Rainey; 2012. [6] Bannister Roger. Brain and Bannister's clinical neurology. Oxford University Press; 1992. [7] Graham Loren R. The ghost of the executed engineer—technology and the fall of the Soviet Union. Harvard University Press; 1993. [8] Wolpert Lewis. The unnatural nature of science—why science doesn't make (common) sense. First Harvard University Press; 1991. [9] Collins Jim, Porras Jerry. Built to last. New York, NY: HarperCollins Publishers, Inc.; 2011. [10] Collins Jim. Good to great. New York, NY: HarperCollins Publishers, Inc.; 2001. [11] Collins Jim. How the mighty fall and why some companies never give in. New York, NY: HarperCollins Publishers, Inc.; 2009. [12] Wade Nicholas. (2003-10-07) “American and Briton win Nobel for Using Chemists' Test for MRIs”. New York Times; 2007. [13] Krummel Thomas M. Personal conversation with Dr. Judah Folkman; 1982. [14] Shellenbarger Sue. “Tactics to Spark Creativity” in Wall Street Journal; 2013. [15] Oppezzo M, Schwartz Daniel. Research report: “give your ideas some legs: the positive effect of walking on creative thinking”. American Psychology Association; 2014. [16] Medawar Sir Peter. Advice to a young scientist. Portions of this work originally appeared in Harper's Magazine and The Sciences; 1979. [17] Krummel Thomas M. personal communication with Dr. Mark Ravitch; 1984. [18] American Board of Surgery (ABS) communication from Dr. Ron Hirschl; 2014. [19] Oldham Keith. Optimal resources for children's surgical care in the United States, from the Task Force for Children's Surgical Care, published in Journal of American College of Surgeons, JACS; 2012. [20] Friedman Thomas. It's a 401(k) World”. The New York Times, The Opinion Pages; 2013. [21] Hennessey John L. From the 13th Annual Fogarty Lecture, “Promoting & sustaining innovation: lessons from Stanford & Silicon Valley, November 11, 2011; 2011. [22] WebSurg online URL: www.websurg.com. [23] Riedel Alexander W. Air Force researchers test Google Glass for battlefield use”. Air Force News Service; 2014.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
APSA Presidential Address
Try again. Fail again. Fail better. Thomas M. Krummel ⁎ Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA Lucile Packard Children's Hospital, Palo Alto, CA, USA
a r t i c l e
i n f o
Article history: Received 13 September 2014 Accepted 6 October 2014 Key words: Pediatric surgery Innovation Failure
Members and Guests of APSA, colleagues and friends. I am deeply grateful for the privilege of serving as your 45th President. There are probably a hundred others in the audience equally or more deserving of this honor, and I fully understand the role of chance and good fortune in such awards. Again, my profound thanks. In its very generous introduction Dr. Albanese graciously omitted the many missteps, mistakes and flat out screw-ups that do not show up on one's CV; nonetheless they form an equally and perhaps more important component of a career, and the inspiration for this address. I feel very much like the proverbial “turtle on a fence post”; when you see one, you know that the turtle didn't get there on its own. As such, I owe deep debts of gratitude both professionally and personally to many, I will enumerate a few. Over a professional career of 40 years spanning five institutions, I am indebted to the students, residents, fellows and faculty at the Medical College of Wisconsin, the Medical College of Virginia, Children's Hospital
⁎ Corresponding author. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jpedsurg.2014.10.026 0022-3468/© 2015 Elsevier Inc. All rights reserved.
© 2015 Elsevier Inc. All rights reserved.
of Pittsburgh, Penn State and the Hershey Medical Center, and Stanford University and Packard Children's Hospital. Those countless interactions and friendships have all made an imprint. I am grateful for many lessons from professional colleagues and friends at APSA and broadly throughout the surgical organizations I've been privileged to serve. Finally to my patients and their families, I am grateful for your lessons and for your demonstration of courage. There's one guy who spans both the personal and professional— Arnold M. Salzberg, MD, HB and an early member of APSA. Arnie was an icon, a mentor, and a friend. I'm one of Arnold's 12 disciples who were inspired to pediatric surgery. Salzberg and the 12 disciples! Arnie's laughing up there someplace (Fig. 1). True story. I'm a junior resident on Pediatric Surgery at MCV in 1979. It had been a terrible week. We had fixed diaphragmatic hernias on two beautiful 4 kg babies and then sat around and watch them die. Nothing to do. The following week a young hotshot, Bob Bartlett, shows up and gives a research conference on a newfangled technology—ECMO. After the talk, Arnie rivets me with his gaze and says: “hey Krummel, how many more kids are we going to watch die before you do something?” With the full support of Dr. Salzberg and Dr. Lazar Greenfield we put together a ragtag ECMO team. Eighteen months into it we reported some real successes at the Surgical Section of the AAP. Arnie was quick to point out “Bartlett proved ECMO could be done, Krummel proved anybody could do it.” The AAP Surgical Section offers the Salzberg Award for Mentorship, there's a good reason for that. Next is that young hotshot Robert H. Bartlett—RHB (Fig. 2). Dr. Bartlett has been a role model and a friend for almost 35 years. He graciously hosted a very young and not very bright PG2 resident at the University of California, Irvine in 1980. I camped out in the NICU at the Children's Hospital of Orange County and tried to be a sponge. Learning from two patients on ECMO, Dr. Bartlett introduced me to the intersection of surgical science and engineering which has remained a foundation and a passion for the rest of my career.
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Fig. 1. Arnold M. Salzberg, MD.
While there are many I would specifically like to acknowledge two “big brothers', Michael R. Harrison, MD and Joseph P. Vacanti, MD (Fig. 3). The two of them created entire new fields—fetal intervention and tissue engineering—through thought and action, and at the beginning, single handedly. Fundamentally, they built things we never thought of, or acted on before. Each of them authored the definitive papers and textbooks. Both have been of enormous service to the field of Pediatric Surgery and the patients whom we serve. I count them amongst my closest friends. Each knows something about failure as well. John and Marian Waldhausen, shown here during Dr. Francis D. Moore's Waldhausen Lectureship, made a huge impact (Fig. 4). John was the founding Chair of the Department of Surgery at Penn State; he recruited me as Division Chief and little did I know he was quietly grooming me to succeed him as the Department Chair. He truly taught me the art and science of leading a department, priceless lessons for the journey West to a troubled Department of Surgery at Stanford in 1998. While in Silicon Valley I've been privileged to learn from two master physician inventors/innovators, Rodney Perkins and Tom Fogarty.
Fig. 2. Robert H. Bartlett, MD.
Between them they are singularly responsible for 50 successful medical technology startups. More than 10 million patients have been treated with their inventions. They epitomize the exploration of new therapies and the expectations of failure along the way. My parents, Jim and Helen, taught me everything about what is important, long before I went to school. They taught me that you don't need much to have a lot and that scarcity and necessity drive innovation. I am privileged to have two terrific brothers and one terrific sister. Finally I am blessed with an extraordinary family, my wife, Susie, and three spectacular children, all of whom are here. They all help me to keep it real and make everything worthwhile. These family foundations are a daily reminder of both my blessings and my responsibilities to others less fortunate. With them I believe everything is possible. Marrying Susie has been the best decision of my life. The most famous painting ever depicting a physician is this one executed by Sir Luke Fields (Fig. 5). Appropriately for all of us in APSA, it depicts a physician puzzling over a sick child. There are many interpretations of this painting: some see the light of dusk and despair, others see the light of dawn and hope. What do you see? Regardless of those interpretations no one can miss the look of care and concern for this child's problem. What was the state of surgical care at the time of the painting? If this child had an intussusception, appendicitis, or even an incarcerated hernia death was likely. Roughly at the same time, Sir John Ericksen, the then “surgeon-extraordinaire” to Queen Victoria, declared “The abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon”. Times have changed. Why? How? Throughout the history of surgery, progress is always about innovation whether in diagnostics, supportive care, monitors, tools, devices, technologies or surgical procedures but progress is inevitably also about failure. Often, to discover ‘what works’, one must plow through an awful lot of ‘what doesn't work’. Entire fields were created out of serial failures. Solid organ transplantation, surgery of the heart and great vessels and laparoscopy were all developed through a series of fits and starts, a series of mistakes and adaptations. The development of surgical devices such as staplers, cardiac valves and the pulse oximeter all painfully evolved after discovering what didn't work. It is these lessons of failure that inform subsequent success and indeed are essential. A brief word about the title. Samuel Beckett was an Irish playwright who was awarded the Nobel Prize in literature in 1969. A profound
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Fig. 3. Michael R. Harrison, MD and Joseph P. Vacanti, MD.
pessimist, he authored the play “Waiting for Godot”. In 1983, in a parody entitled Worstword Ho!, he penned the words, “Ever tried. Ever Failed. No matter. Try Again. Fail Again. Fail Better.” While his view was profoundly dark and pessimistic, mine is profoundly optimistic. An alternative for this talk occurred to me and that was “The F-Word”. I had some concerns that is might be difficult to ever reference a paper with such a title! In the hallway between the locker room and the operating room at Stanford Hospital is a picture of a famous 1895 train wreck at Paris, France at the Garemontparnasse terminal. I've never been sure whether it occupies its current position en route to the OR by accident, as a joke or as a warning. But it is a daily reminder of our responsibilities. I have four simple objectives in this address. 1. Systematically observe lessons of failure in surgery, athletics and medtech innovation 2. Draw “generalizeable knowledge” in failure as a gateway to success 3. Explore the role of what Louis Pasteur called “the prepared mind” 4. Review key megatrends to inform where we should—try again, fail again, fail better In preparation for this I've reviewed hundreds of presidential addresses, the topic is almost some sort of success. So it is with trepidation that we get started.
I first became aware of Robert E. Gross from on his picture (Fig. 6) on Arnold Salzberg's wall and his The Surgery of Infancy and Childhood textbook on his bookshelf. During the early days of ECMO I visited not only Dr. Bob Bartlett but David Collins and others and their offices similarly had the same Robert E. Gross picture and Robert E. Gross book. He was the first President of APSA, founding father of the field and made enormous contributions, in particular with the first ligation of the patent ductus arteriosus, but also with the development of aortic homografts and many broad and deep contributions to our field. What would Dr. Gross know about failure? It turns out, more than a little! He did not match in Surgery at the University of Minnesota (he neglected applications to the MGH and the Brigham). Having been denied a surgical internship, Dr. Gross decided to abandon surgery and he began a pathology residency with Dr. Bert Wolbach at the Brigham. Fortunately, after several years he switched back to a surgical career and the rest is history. In reviewing his career, Dr. W. Hardy Hendren and Judah Folkman commented about his unique perspective because he was “surrounded by the many problems in the Pathology Department”. He understood the complex anatomy not just of cardiovascular problems but across the spectrum of pediatric surgery pathology. When I got back from my ECMO barnstorming tour, I wrote Dr. Gross a letter and in it I observed that his picture and textbook were
Fig. 4. John and Marian Waldhausen.
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Fig. 5. The Doctor.
everywhere, that his pupils had made profound contributions and as such, his legacy was lifelong and now being passed on to me and other of a next generation. I thought nothing more of the correspondence. Two weeks later a letter arrived in my mailbox—the return address was Robert E. Gross, Brattleboro, Vermont (Fig. 7). Dr. Gross began, “it gave me much pleasure to have the warm and good note from you. I'm glad that my old residents tell some of the nice things that happened on my old service and omitted some of the troublesome time which I should have handled in a better manner.” He indeed knew something about problems, mistakes, and failures.
Fig. 6. Robert E. Gross, MD.
Famously Dr. Gross' textbook lacked a chapter on sacrococcygeal teratoma. The story has been recounted by Drs. W. Hardy Hendren and Bob Shamberger that a trainee came to Dr. Gross to ask “how do I manage sacrococcygeal teratoma?” Dr. Gross commented, “it's in the book!” The trainee replied, “Dr. Gross, it's not in the book!” Dr. Gross searched, discovered, indeed, the chapter had been omitted from the book and found the missing chapter manuscript behind the heater register in the office. A perhaps more noticeable oversight, was Dr. Gross' failure to listen to Helen Taussig's suggestion. Dr. Taussig noted that patients with tetralogy of Fallot invariably became much worse when their ductal murmur disappeared, indicating closure of the ductus and elimination of the systemic-topulmonary shunt. Dr. Taussig asked Dr. Gross whether it would be possible to “make a ductus” to sustain such patients. Dr. Gross dismissed the idea; of course he had made a career ligating patent ductus. Alfred Blaylock, however, didn't ignore the suggestion and then the rest is history (Fig. 8). But where did Alfred Blaylock's insight originate? Dr. Blaylock later reported, “while on the faculty at Vanderbilt in 1938…I became interested in pulmonary hypertension.…Might be possible to produce pulmonary hypertension by subclavian to pulmonary anastomosis. Much to our disappointment it failed” [1]. Blaylock thus knew not only that a systematic to pulmonary anastomosis was possible but in addition it would not produce pulmonary hypertension. The stage was set. We all remember Blaylock's successes, but how did he get there? William Longmire recounts William Blaylock's road to success thusly [2]. “I learned of Dr. Blaylock's desire to oxygenate the blood by some extrapulmonary means.…Tests were made injecting oxygen intravenously, by various methods, intraperitoneally, and directly into tissues. All of these methods seemed to be ineffective. Dr. Blaylock had seemed to me to be rather depressed for several weeks prior…I was quite aware of the fact that several major, what might be called “advanced,” operations which he had attempted had not been successful. Each failure seemed to have provoked an accumulated depressive emotional reaction. Finally, I must say my enthusiasm for the idea completely disintegrated when I saw the frail cyanotic infant in the oxygen tent on the East Ward of Harriet Lane.” The first case was successful, electrifying the world. And yet, as Mark Ravitch points out in the Papers of Alfred Blaylock [3] “The patient load was heavy, mortality at first was considerable, and at times…there would be a series of consecutive deaths hard to bear.”
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Fig. 7. Gross letter, pages 1 and 2.
We all remember Cameron Haight as the surgeon to first successfully ligate and divide a tracheal esophageal fistula and successfully perform a primary esophagoesophagostomy thus restoring esophageal
Fig. 8. Trailblazers.
continuity and yet, here are his unedited results of his first seven patients—one survived and in the 4 year period after the first successful case, the aggregated survival was 37% (courtesy of Ron Hirschl). It certainly puts our current ability to thoracoscopically perform the same operation in a very different light. Everyone in this audience knows Thomas Starzl, MD, PhD as an icon. He's a recipient of the Presidential Medal for the Advancement of Science, as well a Lasker Award, the street adjacent to the University of Pittsburgh's hospitals has been renamed Thomas E. Starzl Way. What most people forget are the dark days prior to success. As thoughtfully recounted in his autobiography “The Puzzle People” [4] Starzl comments in Chapter 9, titled “The failed liver transplant trials”, “A pall settled over the liver program, no more patients were entered for more than 3 years.” About this time Dr. Starzl developed hepatitis and was dismissed as Chair at the University of Colorado. Fortunately for him, and for the field, Dr. Henry Bahnson recruited Dr. Starzl to Pittsburgh, created an ideal working environment and resurrected Starzl's career and paved the way for successful liver transplantation. On a deeply personal level, here's a good example. Dr. Albanese was kind enough to comment on the early ECMO experience at MCV. Let me give you the real story. It's 1980, I'm a PG3 resident and we've completed sheep perfusion studies and a huge local chart review to identify patients with predicted 100% mortality. I was called to the newborn ICU for what was anticipated as our first patient, a beautiful 4 kg girl with meconium aspiration syndrome. As we wheeled the ECMO apparatus into the NICU, the patient arrested and required episodic CPR. Both attending physicians were unavailable, one out of town and the other with such bad poison ivy it was impossible to gown and glove. We had two ECMO techs, two dog lab technicians and one newborn ICU nurse (my wife, Susie). You don't see in this faraway picture but a close-up picture shows a right carotid and a left internal jugular cannula. Why?—I tore the right internal jugular vein trying to shove a chest tube cannula in just as CPR was re-instituted…blood was pouring out of the neck. I can't remember how I was even able to control the proximal vein but it was shredded. I figured I had nothing to lose in going to the other side. I got the venous cannula in, 8 days later she came off ECMO. We were lucky with six survivors in a row followed by three straight mortalities. Imagine if the order had been reversed.
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I happened to recount the story to Dr. Judson Randolph as our bike trip was taking us through Nashville in 2012. Dr. Randolph commented “You know, Tom, the Good Lord looks out for ne'er-do-wells, drunks and young surgeons!” All I could say was, Yes sir, Dr. Randolph, I really wasn't sure in which category he placed me, perhaps multiple. Failure in athletics is axiomatic. Every serious gym/track/field/pool/ stadium in the world has athletes forcing themselves to failure…and then beyond. In 1952, Roger Bannister was favored to win the 1500 meters at the Olympics in Helsinki. He finished a disappointing 4th. His comment: “I'd let the nation down”. Two years later, at the Iffley Road Track, he stunned the world with the 1st sub 4 minute mile: He was a medical student at the time. He commented later “Being defeated and feeling that I'd let people down is what led me to go on. I would not have run 3:59:6 if I'd won that gold medal” [5]. For those who dismiss athletic experiences as trivial, Bannister later commented: “Only in something like running can finality be achieved, the sort of finality that is almost perfection. But it is not the kind of perfection that leaves you with nothing to live for. You are not your own executioner because sport is not the main aim in life. Yet to achieve perfection in one thing, however small, makes it possible to face uncertainty in the more difficult problems in life.” Bannister went on to a distinguished career in Neurology, he authored the definitive textbook, Brain and Bannister's Clinical Neurology [6]. Dr. Albanese mentioned the cross country bike ride, it had its originals in failure. In 2007 I attempted to do the California death ride which is 129 miles with 5 monster mountain passes and a total of 15,000 ft (3 vertical miles) of climbing. I crashed, finished only 2 peaks on 70 miles, clearly I was poorly trained. Failure was predictable. In prepping for the Ride Across America (RAAM), I reflected on Bannister's experience, the need for better preparation including mental preparation. The 14 month plan with diligent effort and a first-rate coach who specialized not only in master athletes but also in mental preparation. In my first conversation with Coach Scott Saifer, he asked the question “What's the toughest distance of the RAAM?” He then answered his own question “The 8 inches between your ears”. During our last conversation before I set off on the ride his final comment was “When you think you're going to quit, remember the lessons of surgical training”. NASA has some experience with failure. They hate it, they never forget it, and they learn from it. During the APSA Board of Governor’s Retreat in January 2014, we came upon a 4 ft × 8 ft giant poster on the wall at the Johnson Space Center. It included pictures of each of the Apollo, Challenger and Columbia astronauts who died as a result of failure. The concept was put in slightly terms during an interview with Andy Grove, retired Intel CEO. I had proposed that he do a Fogarty Lectureship, and in the course of getting acquainted he asked me how and why I had come to Stanford. I told him of the epiphany I'd had when I decided I'd rather go to Stanford and fail then forever wonder what might have been. Andy then asked, “What are the key factors for success in Silicon Valley?”, I answered: intellectual capital, financial capital and flat hierarchy. He reminded me, “you missed one—risk capital, the same thing that brought you here!” Over 15 years, we've learned a great deal about failure in the Biodesign Innovation Program. Our stated goal is to teach the process of innovation and create the next generation of medical device inventors and leaders. Over a 15 year period we've had substantial success. • • • • • • • •
More than 750 invention disclosures/patents Multiple abstracts, posters, chapters, manuscripts Biodesign Textbook in its 2nd edition Real world funding success 32 startups; 810 jobs created 135 grads, 8 rookies Birthed 18 other Biodesign Programs worldwide More than 250,000 patients treated
That said, Biodesign has been replete with failure. The entire process of prototyping involves identifying what doesn't work and then moving on to what does.
Two specific cases are illustrative. Matt Callaghan was identified as one of the Top 10 Inventors by Popular Mechanics in 2010. His current iteration is the result of 4 years of sequential failures. James Wall, then a surgery resident but now a Pediatric Surgeon in my department, had a similar experience. James and his team observed an OR case of mine —14 year old patient with a pectus deformity. Preoperatively there was a 45 minute thrash to place an epidural catheter for intra- and post-op pain control. The epidural was ultimately abandoned. Any of you seen a failed epidural? While we pushed ahead with the case, the team observed the problem and was able to bring together both fresh eyes and a “prepared mind”. One of the engineers on the team made the observation, “In the Engineering world we would never think of pushing with in-line pressure to force through a substance and stop suddenly; we would engage with a screw!” An Ah Ha moment! The team prototyped FAST. Within a single day; they demonstrated the ability to engage spinal tissue from a local butcher, using a true-to-scale threaded screw from Ace Hardware. Concepts were refined, over time multiple prototypes were developed and final concept now 5 years later is approaching. This past spring Trinity College in Dublin developed an entire exhibit at their Science Center on the subject of failure—no surprise given that Samuel Beckett is a graduate of Trinity College, Dublin. On the wall beneath the catastrophic failure of a Formula One race car axle failure is the sign “Fail Fast and Cheap. Fail in a Way that Doesn't Kill You!” While this is a new iteration, as I've learned from ‘digging’, it actually echoes the three principles of Peter Palchinsky, a Russian engineer. Palchinsky was a capable mining and civil engineer who spent a great deal of time analyzing the failure of many massive Russian engineering projects. He evolved the following principles: [7] • Try new things, expecting some will fail • Make failure survivable—safe spaces and small steps • Know when and how you failed and learn For his outspoken criticism, he was executed. That's the problem with a Stalin as your Boss! Ultimately what Palchinsky articulated is a variation of Charles Darwin's observation on Evolutions of Species: “It is not the strongest of the species that survives nor the most intelligent, but rather the one that's most adaptable to change.” In summary, I believe objectives 1 and 2 have been well demonstrated. Success often begins with failure, it is routine across very different fields of surgery, athletics and medtech innovation. Failing well is actually the KEY to success. Fail fast, fail cheap and don't get killed, Adapt and learn in an almost Darwinian model. It's fair to say that mindset does matter. How and why did Gross, Haight, Blaylock and Starzl get it right and others not? It begs the perpetual question: “Why are some people so ‘lucky’?” We turn to objective 3 which is to explore Louis Pasteur's concept of “the prepared mind” Prepared minds have always had the greatest success in scientific discovery. Ambrose Pare at the siege of Turin was cut off from supplies to oil which was usually boiled to cauterize wounds. Given the lack of boiling oil he turned to gentle cleansing with soap and water with much improved results and changed the way we think about local wound care. LJM Daguerre first perfected the development of a photographic plate because of the accidental contamination of a cabinet with mercury. Alexander Fleming observed the bactericidal effects of a mold and ultimately identified penicillin. Charles Goodyear discovered that rubber contaminated with sulfur became a much useful compound and developed the process of vulcanization. Finally Percy Spencer noted that the chocolate bar in his pocket consistently melted when he was testing a magnetron. Most of us would have ignored the observation; he identified the heating properties of a magnetron and thus birthed the microwave technology that is present in all of our kitchens. Perhaps no one contributed more than Louis Pasteur. He settled once and for all the fallacy of spontaneous generation. He singularly demonstrated the ability to preserve beer, wine and milk in a process we now know as
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pasteurization. Pasteur saved the French silk industry by solving the riddle of parasite attacks on silkworm eggs and set the stage for “vaccination” in cholera, anthrax and rabies. Either he was the luckiest scientist in history or perhaps he knew something. In 1854 Pasteur was named Dean at the University of Lille and in his inaugural address he declared “In the field of observation, fortune favors only the prepared mind. He later said “Imagination should give wings to our thoughts but when we need decisive experimental proof, imagination must be check and documented by the factual results of the experience.” On top of that, Pasteur had the sagacity to seize on the unexpected result, and not ignore it. Louis Wolpert [8] put it this way “Scientific research is based not on chance but on highly focused thoughts. It is not by chance that it is always the great scientists who have the luck. We are all surrounded all our lives by innumerable ‘facts’ and ‘accidents’. The scientist's skill is to know which are important and how to interpret them.” How might we encourage that? Sometimes it's easier to study the loss of the prepared mind as a prelude to encouraging it. Jim Collins has built a career on the systematic study of organizational success and failure. His books, Built to Last [9] and Good to Great [10] are classics and he most recently authored a book How the Mighty Fall [11]. Jim is a lecturer at the Stanford Graduate School of Business on creativity and has added richness of thought to our Biodesign Program. In his most recent book he pursues a systematically study of the decline in high performing companies. He specifically calls out the loss of the prepared mind in this way. “When the rhetoric of success replaces penetrating understanding and insight (we understand why we do these specific things and under what conditions they would no longer work) decline will likely follow.” “Luck and chance play a role in many successful outcomes, and those who fail to acknowledge the role luck may have played in their own success—and thereby overestimate their own merit and capabilities—have succumbed to hubris.” There are two experts who have gotten it right and said so succinctly. Paul Lautebur [12], Nobel Laureate for his contribution to magnetic resonance imaging put it this way: “You can write the entire history of science in the last 50 years….in terms of papers rejected by Science and Nature.” Our own past president, Judah Folkman (Fig. 9) told me
Fig. 9. Judah Folkman, MD.
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during my Pediatric Surgery fellowship interviews “Tom, there are no experts on the future, just experts in the present” [13]. “Make sure you become an expert in the future.” I had the privilege of nominating Dr. Folkman for a Nobel Prize four specific times, the fourth nomination was sent just before his tragic and premature death. I'd like to think that perhaps, for him, the fourth would have been the charm. There's currently enormous focus on creativity, discovery, invention and innovation. These processes become an essential “skill” in a hyper-competitive world. A report in the Wall Street Journal on April 2, 2013 began to explore the best strategy when stuck on a hard or insoluble problem and how best to increase the likelihood of the “Ah Ha moment” [14]. In interviewing many who have had such moments there are consistent reports of what we now would call “the insight experience”. It always begins at an impasse and the insight frequently comes outside the active search whether in the shower, in daydreaming, or in active exercise. At the time it is often shockingly obvious and complete and there is an accompanying certainty to the concept. Whether it was Archimedes' gold crown composition and his Ah Ha moment in the bathtub, or Pasteur's insights in silkworm disease or Judah Folkman's tumor vessel puzzle or your current unsolved problem, it all begins with the impasse and frequently ends with a sudden insight not while laboring over the problem but by seeing it from another angle. What are conditions to enhance such insights? 1. When at an impasse, stop concentrating on details 2. Search more broadly and involve others. This functionally may represent a move from left cerebral hemisphere to the right. The opportunity to lose a focused consciousness and daydream, think about it in the shower or exercise seems to be a winning strategy. No one knows why. This observation was expanded in a research report in the Journal of Behavioral Psychology in a paper entitled “Give your ideas some legs: the positive effect of walking on creative thinking” [15]. Steve Jobs was well known for his walking meetings as is FaceBook's Mark Zuckerberg. Perhaps you've paced back and forth on occasion to drum up ideas. The study found that walking indoors or outdoors similarly boosted creativity inspiration. The act of walking itself and not the environment seem to be the main factor. Across the board creativity levels were consistently and significantly higher for those walking compared to those sitting. Other research has focused on how aerobic exercise generally protects against long term cognitive decline. This well-executed study demonstrated more and better ideas and positive effects on creative thinking and problem solving with activity: up to a 60% increase in creative output was measured and this appears to be sustained after the activity. Specifically, those problems that require a fresh perspective were consistently better solved. Does this work in the real world? The example of Minnesota Mining and Manufacturing otherwise known as 3M is a good example. Based on intellectual property filing, they are the third most innovative company in the world and the first to hardwire creativity policies. 3M has a specific policy entitled “the Flexible Attention Policy”. It encourages people to take a walk outside, play ping pong or engage in other playful activities. During such 15% time, your thinking and work MUST focus on speculative new ideas, such ideas must be shared with colleagues. 3M has a 75 year history of success as a for-profit company; these policies predate those of Google (which now has their own 20% role). The Post-it Note story is illustrative. Arthur Fry, an engineer in paper products, attended a Tech Forum during his 15% time. At the Forum an adhesives engineer presented a discovery—very weak glue—and asked if anyone had use for such stuff. Fry happened to sing in the church choir and the hymnal pages were frequently marked with scraps of paper which often fell out. Subsequently, Fry was daydreaming during the sermon and suddenly had the insight of a weak glue applied to a small piece of paper marking the hymnal pages and voila birthed the ubiquitous POST-IT NOTE.
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Finally, I'll try to address my thoughts on where we might focus our efforts as we “try again”. In his book Advice to a Young Scientist [16] Sir Peter Medawar suggested “It can be said with complete confidence that any scientist of any age who wants to make important discoveries must study important problems. Dull or piffling problems yield dull or piffling answers. It is not enough that a problem should be “interesting”—almost any problem is interesting if it is studied in sufficient depth.” One of our most literate and distinguished scientists, Medawar later wrote “The human mind treats a new idea the same way the body treats a strange protein; it rejects it”. Well here goes some new ideas. First and foremost I think the theme of this 2014 meeting has been “what direction is the field going.” Our four distinguished lecturers, Drs. Jacques Marescaux, Diana Farmer, Gail Besner and Eric Rose have added enormously to our understanding of lessons learned and options opened. The innovation panel entitled: “Where is ‘the puck going’ in the advancement of our field?” was designed to broaden our thinking beyond basic science investigation. Panel speakers Drs. Brad Rogers, Mike Harrison, David Powell, Gretchen Purcell Jackson, and Craig Albanese covered a broad range of talks suggesting a broad menu of areas to investigate. As we look on new approaches it is worth remembering out core competence. I was privileged to know Dr. Mark M. Ravitch during my time in Pittsburgh Children's Hospital in 1983–1985. Dr. Ravitch was an imposing, and indeed intimidating figure. Woe be it to the junior resident who spoke of taking the patient to “surgery” rather than “to the operating room”. Walking Dr. Ravitch back to his Montefiore hospital office was a unique privilege which I relished. It was a chance to see his incisive mind at work and his thinking has shaped mine to this day. I recall his thoughts about the definition of surgery as follows: “After all, Tom, ‘Surgery is not a place or procedure, but an intellectual discipline, characterized by operative procedures but defined by an attitude of responsibility toward the care of the sick’” [17]. So though we may solve problems differently as the years go by, it doesn't diminish us as surgeons. I would like to focus on four personally and highly selective megatrends. 1. 2. 3. 4.
Pediatric surgical workforce “Half the sky” Tools of the trade Ubiquitous computing
1. Workforce The number of board-certified pediatric surgeons has quadrupled from 1975 to 2013. The number of complex index cases is flat or diminished. There are many reasons including a historically low birth rate (1960-3.5/2010-1.89), selective terminations for malformation, and a relatively stable incidence of pediatric tumors. Shared concerns have bubbled up through the leadership of APSA, the American Board of Surgery [18], the American Board of Pediatric Surgery, the American Pediatric Surgical Training Program Directors meeting and the AAP Executive Committee. Specifically, we noted our new APSA member case logs are looking “thin” and recertification case logs indicate that the average Pediatric Surgeon performs 9.5 index cases per year, less than one a month. Past president Keith Oldham's Optimal Resource [19] work has focused on the attributes of facilities, we wanted to broaden to understand the attributes of our Pediatric Surgeons. Regrettably, there has been a price of de-regionalization. It has been well reported that in patients with pyloric stenosis, appendicitis, necrotizing enterocolitis that we have worse outcomes at low volume sites. This could be construed as either a problem or an opportunity but it certainly can't be ignored. Accordingly APSA has commissioned a Workforce Study in conjunction with the American College of Surgeons working with the Sheps Center at the University of North Carolina. Over the next year an exhaustive study of case volumes, demographics and practice patterns will be reviewed and workforce needs modeled for the next 15 years. This will, I believe, be a major theme for incoming President, Michael Klein. 2. Half the sky As I was preparing the Ternberg Lecture in 2011 I came upon a picture of the housestaff at Barnes Hospital in the mid 1950s (Jesse Ternberg as the only woman in a sea of men). I will compare that to the Stanford University Department of Surgery Chief Residents in 2010–2011 (five of six were women). We have come a long way. It was only in 1934 that Harvard Medical School went co-ed. The majority of medical students are now women. Women are no longer just pediatricians, they represent more than 20% of the practicing surgeons in the United States and as high as 40%
Fig. 10. Rigid and flexible scopes.
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at IRCAD. “The device as a procedure” has become more widespread. It is epitomized either in the Nova-Sure or BARRX device where RF energy is precisely applied and controlled not by the surgeon but by the device itself, thus a mucosal ablation is consistent and reliable and based on tissue resistance. No more over eager surgeon to overuse and no more timid surgeon to underdo—the device monitors and is tuned to tissue effects. 4. Ubiquitous computing
Fig. 11. Google glass contact lens.
of our surgical trainees are women. Such progress notwithstanding, there remain important and serious concerns about “the glass ceiling”. Additionally, progress in the United States is by no means reflected broadly worldwide. The Association of Women Surgeons Leadership Council's been an enormous force over the last two decades. During my last year as a Director of the American Board of Surgery we were able to change an old and arcane rule. Prior to that time, if a resident missed more than 4 weeks in any given training year, the entire year was discredited. Since the average maternity leave is 6 weeks, this functionally eliminated pregnancy during residency training as an option. What was informally known as “The Krummel Rule” allowed for flexibility for Training Program Directors and eliminated a ridiculous penalty for pregnancy. 3. Device trends In general we will see increasing complexity and thus increasing risk in medical/surgical devices. The risks, specifically, are technical due to complexity and expense due to development. I believe we will see merging platforms of rigid and flexible scopes and image guidance (Fig. 10) and we are very taking our lessons from Professor Marescaux
It's worth stepping back and remembering what has happened in the last decade. Tom Friedman put it this way: “Something really big happened in the world's wiring in the last decade but it was obscured by the financial crisis and post-9/11 era.” We went from a connected world to a hyper-connected world. I'm always struck that Facebook, Twitter, 5G iPhones, iPads, ubiquitous wireless and Web-enabled cellphones, the cloud, Big Data, cellphone apps and Skype did not exist a decade ago [20]. John Hennessey, president of Stanford University and member of the Board of Directors of both Google and Cisco made the following observation when he delivered the Fogarty Lecture. Professor Hennessey said: “There are two major trends in computing today—mobile and social. Nothing else matters” [21]. Ubiquitous computing has pulled the memory game off the table. We've gone far beyond Websites to smart tools, a hyper-connected medical system and a new definition of a patient. As Professor Marescaux has demonstrated, the massive, open, online course (MOOC) is embodied in WebSurg [22]. This has provided postgraduated education in minimal access surgery with 1.4 million viewers in 213 countries. There are now some 30,000 consumer facing apps on smart phones. Remote monitoring hubs and sensors are now available on Amazon. mHealth for physicians and professionals are ubiquitous, we're now approaching the next generation of wearable technology. In particular, I would like to focus on wearable visual computing currently embodied in the Google Glass®. The Air Force is now testing Google Glass® for battlefield use, coordination of resources and real time communication [23]. How might this be used in our field? What if it were possible for a trainee or a peer to actually see what the surgeon is seeing, perhaps with the addition of telestration or other coaching tools?” How does Dr. Shamberger approach a neuroblastoma, through his eyes-shared infinitely?
Fig. 12. New definition of patient.
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By way of summary, the lessons of surgical history, athletics and medtech innovation show that failure is a frequent gateway to success. It's not about avoiding failure, it's about failing well, which means failing fast, failing often and failing cheap but not getting killed. I hope I've suggested to you that the prepared mind is most likely to emerge with the best idea and have offered some strategies for how to facilitate that prepared mind. Finally, selected megatrends might direct your attention. I'll leave you with two thoughts. The attached cartoon “Early Experiments in Transportation” is insightful (Fig. 13). Indeed the wheel may be used for personal transportation but probably not in the manner depicted. But with the willingness to Try Again, Fail Again, Fail Better, Thor may eventually ride a bicycle or a Segway. One final thought: “The Art of Surgery is not yet perfect and advancements now unimaginable are still to come. May we have the wisdom to live with this with grace and humility.” As true today as it was when Halsted said it over 100 years ago. Again, my thanks and gratitude to the membership of APSA for the privilege of serving as your president. References
Fig. 13. Early experiments in transportation.
At the site linked below is a 90 second video watching what Roger Federer sees as he plays tennis. Anyone who has ever picked up a tennis racket will be stunned at the speed at which he plays (http://mashable. com/2014/05/21/roger-federer-google-glass/). For a surgeon in the operating room how might Google Glass® be augmentive? One could imagine the value of a heads up view of a checklist such as a WHO timeout, the possibility of looking up information in real time such as what is the dose of dantralene for malignant hyperthermia, it could be useful for video capture and distribution and it may allow real time communication between consultants and experts. It's not possible to show you a video of a surgeon but I can show you a food truck chef in what might be call “a kitchen operation” (http:// www.youtube.com/watch?v=H05At3ohbRE&feature=kp). Hard to know how this may play out, there will certainly be uses, successes and inevitable failures. For those that are concerned about the distraction of Google Glass®, there were similar concerns expressed about the use of headphones when the Sony Walkman was introduced some 30 years ago. And beyond that, is the theoretic possibility of providing images directly on a contact lens (Fig. 11). Today we tend to imagine the patient in the hospital. Tomorrow we can imagine a very different image (Fig. 12). Sensors, perhaps actuators and hyper-connectivity allow monitoring and perhaps care ANYWHERE. Shades of Andy Grove's “Shift Left” presentation.
[1] Blaylock A. CV Surgery Past & Present. NIH Lecture Series; 1963. [2] Longmire William. In: Ravitch Mark M, editor. The Papers of Alfred Blaylock, vol. I. Baltimore, MD: The Johns Hopkins Press; 1966. [3] Ravitch Mark M, editor. The Papers of Alfred Blaylock, vol. II. Baltimore, MD: The Johns Hopkins Press; 1966. [4] Starzl Thomas. The puzzle people: memoirs of a transplant surgeon. Pittsburgh, PA: University of Pittsburgh Press; 1992. [5] Reuters. Reported by Venetia Rainey; 2012. [6] Bannister Roger. Brain and Bannister's clinical neurology. Oxford University Press; 1992. [7] Graham Loren R. The ghost of the executed engineer—technology and the fall of the Soviet Union. Harvard University Press; 1993. [8] Wolpert Lewis. The unnatural nature of science—why science doesn't make (common) sense. First Harvard University Press; 1991. [9] Collins Jim, Porras Jerry. Built to last. New York, NY: HarperCollins Publishers, Inc.; 2011. [10] Collins Jim. Good to great. New York, NY: HarperCollins Publishers, Inc.; 2001. [11] Collins Jim. How the mighty fall and why some companies never give in. New York, NY: HarperCollins Publishers, Inc.; 2009. [12] Wade Nicholas. (2003-10-07) “American and Briton win Nobel for Using Chemists' Test for MRIs”. New York Times; 2007. [13] Krummel Thomas M. Personal conversation with Dr. Judah Folkman; 1982. [14] Shellenbarger Sue. “Tactics to Spark Creativity” in Wall Street Journal; 2013. [15] Oppezzo M, Schwartz Daniel. Research report: “give your ideas some legs: the positive effect of walking on creative thinking”. American Psychology Association; 2014. [16] Medawar Sir Peter. Advice to a young scientist. Portions of this work originally appeared in Harper's Magazine and The Sciences; 1979. [17] Krummel Thomas M. personal communication with Dr. Mark Ravitch; 1984. [18] American Board of Surgery (ABS) communication from Dr. Ron Hirschl; 2014. [19] Oldham Keith. Optimal resources for children's surgical care in the United States, from the Task Force for Children's Surgical Care, published in Journal of American College of Surgeons, JACS; 2012. [20] Friedman Thomas. It's a 401(k) World”. The New York Times, The Opinion Pages; 2013. [21] Hennessey John L. From the 13th Annual Fogarty Lecture, “Promoting & sustaining innovation: lessons from Stanford & Silicon Valley, November 11, 2011; 2011. [22] WebSurg online URL: www.websurg.com. [23] Riedel Alexander W. Air Force researchers test Google Glass for battlefield use”. Air Force News Service; 2014.
