Disruptive visions: a robot is not a machine...
Systems integration for surgeons
R. M. Satava
1,2,3
1
Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
2
Defense Advanced Research Projects Agency (DARPA), Arlington, VA, USA
3
Telemedicine and Advanced Technology Research Center (TATRC), US Army Military Research and
Materiel Command (USAMRMC), FT. Detrick, MD, USA
Received: 7 July 2003/Accepted: 26 August 2003/Online publication: 19 March 2004
Abstract. The discipline of surgery has become even
more complex with the rapid introduction of revolu-
tionary technologies. Laparoscopic surgery is just the
simplest and first of these new directions. Robotic sur-
gery and image-guided therapy are the next generation.
As biosurgery and other modalities are introduced, the
complexity will increase exponentially. In order to un-
derstand and utilize the new technologies, surgeons need
to be grounded in the science of systems integration. The
pervasive influence of this new requirement, as well as
the skills, education, training, and assessment needs, are
defined.
The surgeon prides him(her)self on being independent,
in charge, and above all, knowledgeable about the pa-
tient, the procedure, and the medical care plan. This has
been a defining characteristic, which has sufficed until
recently. Although diagnoses could be difficult, comor-
bid factors significant, and the surgical procedure com-
plex, all these components had been within the
knowledge, experience, and immediate control of the
surgeon. However, over the past few decades, technol-
ogy has imposed exponentially increasing demands up-
on all these factors. The result has been increasing
specialization in order to remain an expert, but in a
decreasing area. There has been a gradual relinquishing
of expertise and authority of total patient care, while
maintaining the aura of being the ‘‘captain of the ship.’’
In order to provide the highest quality of care, the sur-
geon is now dependent upon an ever enlarging cadre of
personnel from nurse to anesthesiologist to technician to
billing coordinator.
In a similar fashion, the task of integrating patient
care has logarithmically increased. What was once the
standard of care with a few blood tests, an x-ray or two,
and knowledge of a few antibiotics and a dozen other
medications or surgical procedures, has now escalated to
literally dozens of modalities and choices in every aspect
of care. Along with this technological explosion was
introduced the enormous burden of patient education
and consent, audit and oversight, and accurate billing
for services.
The system broke! Or rather, because there was no
system to bind everything together, things fell apart. One
dramatic result was ‘‘To Err Is Human,’’ a report by the
Institute of Medicine of the National Academy of Science
in November 1999. One of the seminal revelations of that
report was that (to paraphrase) ‘‘it is not the doctor’s
fault, it is the system’s fault.’’ Although the surgeon is
ultimately responsible for the care of the patient, the
analysis indicated that the majority of errors were a
consequence of a series of minor misadventures that ac-
cumulated within the system over time and eventually
crossed a threshold and resulted in a critical mistake.
However, by inference, the physician is indeed to blame
because (s)he did not understand one of the most basic
concepts in science and engineering—systems integration.
Background: An analogy to other industries and
professions
Central to the education of any scientist or engineer,
beginning in the first class in college and continuing
throughout postdoctorate training and practice, is the
absolute requirement to understand the overall problem,
the individual components, and how each part contrib-
The opinions or assertions contained herein are the private views of
the authors and are not to be construed as official, or as reflecting the
views of the Department of the Army, Department of the Navy,
the Defense Advanced Research Projects Agency (DARPA), or the
Department of Defense
Correspondence to: R. M. Satava
Surg Endosc (2004) 18: 617–620
DOI: 10.1007/s00464-003-8233-7
Ó Springer-Verlag New York, LLC 2004