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Turf wars and silos—the effect of disruptive technologic innovation in the treatment of cerebral and peripheral vascular disease

It is with interest and enthusiasm that we read the editorial comment authored by Hopkins et al [1]. The authors describe the traditional organization of medicine, which has led to the creation of department silos. They very elegantly play out the problem of turf wars because of this silo system and correctly point out that this approach led to tremendous advantages and expertise in that physicians were able to concentrate their energy and efforts and become true specialists. The authors note that turf wars continue to exist today driven by a number of factors including actual and potential declining reimbursement, changes in training programs with increased interest in organ system rather than specific organs, development of miniaturization techniques and less invasive approaches, and the advances of imaging, which allow subspecialty physicians to perform and interpret images. We define all of these factors as disruptive technical innovations. These changes are not limited solely to health care. The business literature is laced with many classic case reports of companies that have both floundered and flourished because of disruptive technical innovations. One of the classic cases described in business schools is that of the company that transformed a disruptive technology to their advantage [2]. Crown Cork and Seal was a major producer of cork-lined bottle caps at the turn of the century. As disruptive technological innovations continued in the bottling business, this corporation had to make numerous decisions on how to proceed. Were they simply to remain a bottle cap maker or were they in the business of manufacturing containers—metal cans, glass bottles, bottle caps, and plastic bottles? They chose to respond to a changing market place and have evolved into a corporation with operations in 42 countries employing over 24,000 people and net sales of $6.9 billion. Are vascular surgeons going to continue to simply be surgeons? Will cardiologists continue to only care for the vessels of the heart? Will interventional radiologists continue to perform interventions in isolation without preoperative assessments and postoperative care? We believe that all disciplines involved in the care of cerebrovascular and peripheral vascular patients should respond to the challenges that disruptive technology presents and not simply remain isolated and stagnant in a turf battle. The question of how to overcome this turf war is a difficult one. In business, different approaches are available. One such approach is simply to acquire innovative technologies by purchasing another corporation. Another approach is joint ventures and mergers. The editorial comment by Hopkins et al. suggest that in the field of medicine and specifically in the field of cerebral vascular and peripheral vascular care, mergers would work best [1]. Not only would they be more efficient and streamline patient care, but they would also reduce the number of human errors that occur when treating these patients. The difficulties with close collaboration are potentially tremendous. Breaking down silos and avoiding turf wars is potentially a difficult problem—in some instances, an insurmountable problem. Although our situation is unique in that we are a large multispecialty group of salaried physicians, we describe how a merger was successfully accomplished at our institution. As was successfully pointed out by Hopkins and coauthors, the first potential step is communication. This was accomplished here by fortnightly ‘‘vascular’’ conferences. These multidisciplinary conferences helped reduce the animosity among the groups and increased proximity. Getting to know the perceived adversary went a long way to dispel preconceived notions. After analyzing some of the business literature, it became obvious that communication was only a first step. The next step was to recognize that the whole is significantly greater than the sum of its parts. This is not just a true emotional statement, but also a fiscal statement. By effectively utilizing all talents and facilities, the group benefited with increased volumes for all the subspecialties.