**3.2 The surgeon as an innovator and the process of adopting new technology**

Although surgical training is based on apprenticeship, where the student learns from the master and replicates the master's actions exactly, the advancement of surgical capabilities has always relied heavily on the innovation and adoption of new technologies. Throughout history, the desire to help their patients has motivated surgeons worldwide to be creative in finding new solutions to their problems [8]. The evolution and adoption of change within the actual surgical practice, however, is rather complicated. Some surgeons are constantly innovating by customizing therapies and procedures to meet the uniqueness of each patient, while most continue to follow the path that was laid out by their mentors, often reluctant to adopt new technologies. As such, the integration of novel technologies or procedures into a surgeon's daily practice is influenced by many factors, including the possible benefit the innovation provides to the patient, the patient's demand for it, the learning curve

required for skill acquisition by the surgeon, and the amount of disruption it would create within their practice [9]. Take for example, laparoscopic cholecystectomy; it took only four years from its introduction, to become the gold standard for gallbladder removal, as this procedure had obvious and very tangible benefits for the patients compared to open cholecystectomy, and the amount of disruption to the surgical practice was low. In contrast, laparoscopic simple nephrectomy attained only a mere 20% acceptance rate by surgeons thirteen years after its introduction – most likely due to the lack of perceived benefit of changing the standard of care by the surgeons [10]. The question then arises, how does one promote and move forward a new concept so that it can be adopted?

The process by which a cohort adopts a new concept (idea, technology, procedure, etc.,) can be studied and understood with the Technology Adoption Curve (TAC). TAC is a sociological model that divides individuals into five types of people with different desires and demands, and explains what it takes for each of these groups to adopt an innovation. These five groups are the innovators, the early adopters, the early majority, the late majority, and the laggards (**Figure 1**) [11].

The TAC model, used to describe adoption in the general population can be extrapolated and applied to the adoption of technology by surgeons [12].

*Innovator* surgeons are enthusiastic about new technologies and are willing to take the risk of failure. They are willing to test a new procedure even if it is in experimental stages. *Early adopters* are the trendsetters, they are also comfortable with risk, but they want to form a solid opinion of the technology before they vocally support it. These surgeons are comfortable trying a novel procedure that has enough published literature to be regarded as safe.

Surgeons in the *early majority* are interested in innovation but want definitive proof of effectiveness. The benefits of a procedure are more important to them than

#### **Figure 1.**

*Technology adoption curve. Bell-curve represents the variation of adoption, and S-curve represent the accumulated adoption over time.*

*Human-Machine Collaboration in AI-Assisted Surgery: Balancing Autonomy and Expertise DOI: http://dx.doi.org/10.5772/intechopen.111556*


#### **Table 2.**

*Stages of surgical innovation according to Barkun et al. and how they compare to the TAC model.*

the novelty. The *late majority* are averse to risk, as such, they need to be convinced that the new procedure is worth their time. While *Laggards* are skeptical and wary of change, making them reluctant to change, preferring to continue with what is familiar to them.

In an effort to better relate the model to evidence-based practices like surgery, Barkun et al. proposed some adaptations, allowing for critical appraisal and assessment of the technology. In their model every stage would require peer review, thereby promoting a more scientific approach to the application of new technology in surgery (**Table 2**) [13].

On average, for a new concept to be considered adopted, 20% of people must have already begun to use the technology [9], in other words, some but not all people in the *early majority* group of the TAC. For this to happen with AI in the OR, the benefit of the technology must be proven beyond the proof-of-concept stage. Once the technology has been proven to be safe and beneficial then it will be easier to convince more individuals to try it, thereby promoting wider spread acceptance, adoption and eventually integration into daily practice.
