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The introduction of new technology.

Technology in its broadest sense is now more important than ever in the practice of surgery in Canada. This technology can be as wide-reaching and universal to medical practice as the computerized medical record or digital radiography, or as specific as a new type of laparoscopic instrument or new stent for the management of coronary artery disease. 
 
The issues around new technology are, in my opinion, rather poorly understood, and to my knowledge, there is very little guidance on the most effective way to introduce new technology to medical practice.1 
 
Orthopedic surgery is an excellent example of how technology changes the practice of medicine. The routine use of intramedullary nailing in the management of femoral shaft fractures is now the standard of care throughout North America and Europe. Not that long ago, however, closed intramedullary nailing of femoral shaft fractures was a specialized procedure, done only in certain hospitals by specifically trained practitioners, using expensive medical imaging devices and relatively expensive implants. Thirty years ago, many patients with femoral shaft fractures in this country were being treated by traction with balanced suspension. A recent trip to Uganda to participate in some teaching brought me back to that era of fracture care. Dozens of patients were being treated by means of traction for femoral shaft fractures. The “new technology” of intramedullary nailing had not yet penetrated this hospital, not because the surgeons were ignorant of the technique involved and not because the implants were unavailable, but because the infrastructure required to introduce the technology was not there. 
 
The hospital has the final say in the introduction of surgical technology. If the hospital wants to do laparoscopic surgery, then it will be done, because all the necessary support systems for minimally invasive surgery will be put into place. If the hospital decides that it wants to do navigated total hip replacements or total knee replacements, then the necessary equipment will be provided. The hospital, however, will not make this decision in a vacuum. The people who run the hospital, control the budget and wish to keep the hospital current and relevant seek advice from the practitioners working there about “what's new” in surgery. 
 
I think all of us feel that we should advocate for new innovations in surgical practice, and this advocacy role frequently extends into our positions at hospitals and universities, clinics and patient care centres. There is inevitably an adversarial edge to this advocacy, since the resources available for new technology introduction are limited (in terms of both money and infrastructure), and therefore not everyone is going to get what they need to introduce “their” new technology. 
 
We should act together to develop a system by which technology can be introduced in a way that ensures that a new technology is safe, efficacious and affordable. New technology is fun, but its relevance to the furtherance of patient care is sometimes lost in the enthusiasm we all have for something novel. It must be remembered that not all new technology is successful, and that the acquisition of new knowledge or skills may occasionally carry with it a marked increase in performance error. We also must remember that every failed new technology carries with it a considerable human cost in terms of patient suffering. It is our role as patient advocates to minimize patient cost and maximize patient benefit when introducing new techniques, instruments or implants. 
 
James P. Waddell, MD, FRCSC Coeditor