Author: Alan M. Scarrow
We are living through a remarkable moment in history-a time of revolution. Over the past 200 years, our ancestors lived through three other industrial revolutions: looms and textiles in the early 19th century, steam and rail in the late 19th century, and oil and mass production in the 20th century. Today we are in the midst of a fourth revolution in computing and digital technology that began in the 1970s. Each of the three prior revolutions set off a string of disruptions that changed our culture in profound ways. This one is no different.
It is not a question of whether computing and digital technology is disrupting our culture, it is only a matter of timing and degree. Industries like media, entertainment, and banking that create a product or service more easily digitized, were disrupted early. Others that rely heavily on manpower and expensive assets to provide a product or service like agriculture, manufacturing, and healthcare have been more insular. But automation is a deep and unstoppable force. Even people who resisted transformation in an insular industry like automobile manufacturing could not remove the opportunity for others to do so. Cars built by hand in the third industrial revolution are now largely made by robots. But eliminating the physical labor of manufacturing cars has merely been a check point on the way to further automation. During this fourth industrial revolution, those cars no longer require people to drive them.
What was not obvious at the beginning of the digital revolution was that technology does not play favorites between physical and mental labor. All industries, no matter how insular, are being disrupted in ways that threaten old ways of thinking and working. Today, money can be invested without financiers, legal work done without lawyers, buildings designed without architects, and coding completed without programmers.
Neurosurgery is no different. The forces of technology, culture, economics, and education are making their impact and disrupting our profession in ways that were hard to foresee even a few years ago.
Compared to past generations, we are living in a moment that feels even more temporary. In the 1950s, the average lifespan of an S&P 500 company was sixty years-today it is fifteen.1 As a result, people can no longer rely on a single company or organization to fund a salary, benefits and retirement over the course of their career. Millennials sense this more than Generation Xers or Baby Boomers. By the end of 2020, two out of three millennials expect to have moved from their current job with only 16% expecting to be at the same company in a decade.2
When we switch jobs, those jobs are predominantly short term or, in Millennialspeak, "gigs". Net employment growth between 2005 and 2015 came entirely from alternative employment such as consulting, freelance, self-employment, independent contracts or part-time work.3 The temporary nature of this work is making an impact on the teams formed within those organizations that are responsible for executing new initiatives and bringing about change.
Traditionally, organizations have been enabled by what they and the people employed by them know, own or control. When that exclusivity is gone, the value those organizations deliver is also gone. For example, as legal knowledge has disseminated from attorneys to the Internet in the form of sites like LegalZoom, there is less need for attorneys. As a result, applications to law school are down 40% over the past 10 years.4 This same phenomenon is now happening in healthcare as knowledge that was once exclusive to physicians is broadly distributed amongst sites like WebMD and open source journals.
While this change has come slower to neurosurgery, other medical specialties are feeling it more acutely. Traditional OB/GYN practice in some areas are being "biohacked" by a group of self-help oriented lay women who offer services such as urinalysis, cervical cancer screening, and menopause therapies. These self-described "GynePunks" may have a radical approach from the perspective of most physicians, but what they are doing is possible only because there is demand for a service that is either unavailable or unaffordable to the patients they serve in a more conventional setting.5
Besides the broad distribution of medical information, there is another, more disturbing explanation for the rise of alternative healthcare providers-people have less trust in traditional medicine. Over the past decade, public trust surveys show that trust in "people like me" has reached higher levels than academic experts or doctors.2 Thus when information is freely distributed, light is cast into areas of darkness that can erode traditional models of power and leadership.
Many contemporary organizations are sensing this power shift and taking action. They are creating leadership structures that are not led by individuals but rather are comprised of crowds that connect and share information to solve specific problems. The nature of these leadership structures is not necessarily less engagement, but less permanence and less dominance by individuals-particularly those that are achievement oriented.
Another consequence of the broad distribution of information and automation in this fourth industrial revolution is that there is less need for individual brainpower. College graduates with higher cognitive skills in areas like math, engineering and science are using those skills less. Brainpower required by college graduates peaked in the year 2000 and is now at levels comparable to 1980 as jobs that were once the exclusive purview of people, are increasingly done by computers.6
A common pattern for the automation of higher cognitive skill jobs is that they are first outsourced to the countries that can do it cheapest. For example, coding, web applications and customer support are often outsourced to countries with large numbers of college graduates willing to work for less than U.S. college graduates. But that is only a temporary strategy. As technology advances, jobs or tasks that can be outsourced are eventually automated. When rules of thought can be written down, those rules can be turned into algorithms. Algorithms can then be turned into code that can run a computer or guide a robot to eventually accomplish the same jobs and tasks.
While cognitive skills may be less valuable in 2018, what has increased in value are the "soft" skills-those that enable individuals to collaborate, build relationships, empathize, influence and lead. Those skills are less easy to automate because they are innately human, person-to-person activities that require trust. Industries like healthcare and education are filled with jobs that require those skills. As a result, education and healthcare jobs have doubled as a percentage of total jobs since the 1970s. Today there are 16.7 million people in healthcare with an 18% increase expected in the next 10 years.7
The rapid distribution of knowledge has educated more people and made it possible for those people to create even more knowledge. The expansion of knowledge has driven greater specialization in almost every industry. Greater financial information drove the need for chief financial officers in the 1970s, more knowledge about marketing drove the creation of the chief marketing officer in the 1980s and as data sharing between employees became more important in the 1990s, chief information officer positions were created. Healthcare is no different. The general internist of the 1950s has now specialized into cardiology, interventional cardiology, interventional diagnostic cardiology and interventional therapeutic cardiology because more knowledge created the need for focus and specialization.
As individuals have become more specialized, teams have had to become bigger in order to solve broad, complex problems. The most influential work in medicine, science and engineering is done by such teams. Team publications are 530% more likely to be frequently cited than those done by individuals.6 Additionally, those teams are more diverse as measured by race, ethnicity, sex, and language. This is particularly evident in healthcare. While only 35% of physicians are female, 85% of Advance Practice Nurses and 90% of Registered Nurses are female. Today, nearly two-thirds of healthcare workers are white but that will change over the next ten years as people of Hispanic heritage become a larger portion of the population.8
There is a great deal of concern about the cost of healthcare in the U.S, particularly its effect on individual wallets and long-term national debt. Today, the fastest growing health insurance plan in the U.S. is the high deductible health plan. In these plans, the first $1,350 of cost is the responsibility for individuals and the first $2,700 for families. What makes that a problem for hospitals and physicians is that 57% of Americans have less than $1,000 cash and 39% have no cash at all.9 With many not having the resources to meet healthcare costs, both hospital and public debt has risen. In 2017, U.S. hospitals took on $27.7 billion in new debt compared to $9.4 billion in 201410 while net operating margin for non-profit hospitals dipped to an unsustainable 2.7%11
At a federal level, debt continues to climb up to levels hard to comprehend. Today U.S. debt sits at just over $20 trillion, which is 106% of gross domestic product (GDP)-a percentage not seen since World War II.9 Going forward, the greatest contributor to growth in the deficit will be the interest on the existing debt while the second largest contributor of growth will be healthcare costs. This may not be an existential threat to our generation but very well may be to our children and grandchildren.
The collective impact of technology, cultural, educational and economic trends during this fourth industrial revolution has been profound and will progressively disrupt healthcare. Technology is allowing the collection of huge amounts of physiologic, behavioral and cost data. That data is enabling a shift in focus to population metrics such as cost per patient, case mix index, all-cause outcomes and net operating income. As this technology evolves, more digitized and instrumented technologies will drive care to become more algorithmic.
In order for neurosurgeons to be successful in this environment, we will need to adapt and shift our skill set. In addition to the cognitive and technical skills necessary to provide state-of-the-art neurosurgical care, successful surgeons must also be capable of leading tech savvy, collaborative teams that are focused on short-term, specific problems. Care teams must be able to empathize with one another and communicate effectively across ethnic, cultural and language differences. In addition, neurosurgical leaders with a working knowledge of government regulation and drivers of cost will have an additional advantage as government involvement and a focus on cost control will spur further disruption in healthcare.
Successful neurosurgeons will also embrace a paradox in the coming years as greater knowledge and information stimulates further specialization while also requiring collaboration with larger teams of specialists, advance practice providers, nurses, therapists and other healthcare workers. That shift will reward the "soft skills" of leadership and management that are less emphasized today. The ability to influence through emotional and social intelligence in a fashion that feels more peer-to-peer and less leader-to-subordinate will advance success even further.
Disruption in healthcare and our profession is happening quickly. Technological, cultural, educational, and economic changes are accelerating this disruption. As a profession, let us not be caught flat footed and commit ourselves to developing skills that will allow neurosurgeons to continually succeed during this time of revolution.
IN ADDITION TO THE COGNITIVE AND TECHNICAL SKILLS NECESSARY TO PROVIDE STATE-OF-THE-ART NEUROSURGICAL CARE, SUCCESSFUL SURGEONS MUST ALSO BE CAPABLE OF LEADING TECH SAVVY, COLLABORATIVE TEAMS THAT ARE FOCUSED ON SHORT-TERM, SPECIFIC PROBLEMS.
1)Sheetz, Michael. Technology killing off corporate America: Average life span of companies under 20 years. “http://www.cnbc.com/2017/08/24/technology-killing-off-corporations-average-lifespanof- company-under-20-years.html” www.cnbc. com/2017/08/24/technology-killing-off-corporationsaverage- lifespan-of-company-under-20-years.html. Accessed 7/3/18.
2) Heimans, Jeremy, Timms, Henry. New Power: How Power Works in Our Hyperconnected World—and How to Make It Work for You. Doubleday; 2018.
3) Mulcahy, Diane. The Gig Economy: The Complete Guide to Getting Better Work, Taking More Time Off, and Financing the Life You Want. AMACOM; 2016.
4) Caron, Paul. Going To Law School Is Becoming A Thing Again. http://taxprof.typepad.com/taxprof_blog/2015/07/going-to-law-school-is-becoming-athing- again.html. Accessed 7/3/18.
5) Oakes, Kari. GynePunks: A hacker’s guide to reimagining women’s health. https://www.mdedge. com/obgynnews/article/103599/gynecology/ gynepunks-hackers-guide-reimagining-womenshealth. Accessed 7/3/18.
6) Colvin, Jeff. “https://www.amazon.com/Humans-Are-Underrated-Achievers-Brilliant-ebook/dp/ B00OZ0TLBK/ref=sr_1_1?s=books&ie=UTF8&qid=15 32621904&sr=1-1&keywords=humans+are+underrat ed+by+geoff+colvin”Humans Are Underrated: What High Achievers Know That Brilliant Machines Never Will. Portfolio; 2015.
7) Gooch, Kelli. Healthcare sector jobs projected to increase 18.1% by 2026: 5 takeaways. www. beckershospitalreview.com/workforce/healthcaresector- jobs-projected-to-increase-18-1-by-2026-5- takeaways.html. Accessed 7/3/18.
8) US Bureau of Labor Statistics. https://www.bls.gov/cps/cpsaat18.html. Accessed 7.3.18.
9) PR Newswire. 57% of Americans Have Less Than $1,000 in Savings. “http://www.prnewswire.com/news-releases/57-of-americans-have-less-than-1000- in-savings-300516664.html” www.prnewswire.com/ news-releases/57-of-americans-have-less-than-1000- in-savings-300516664.html. Accessed 7/3/18.
10) Barkholz, Dave. Hospitals handling growing debt loads—for now. “http://www.modernhealthcare. com/article/20170622/MAGAZINE/170629974” www.modernhealthcare.com/article/20170622/MAGAZINE/170629974. Accessed 7/3/18.
11) Gooch, Kelli. Moody’s: US nonprofit hospitals see decrease in median operating margin. “http://www. beckershospitalreview.com/finance/moody-s-usnonprofit- hospitals-see-decline-in-median-operatingmargin. html” www.beckershospitalreview.com/finance/moody-s-us-nonprofit-hospitals-see-declinein- median-operating-margin.html. Accessed 7/3/18.
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