The 100-Year Journey From Surgeons with Reputations to Robots with Precision

If you're an engineer trying to figure out where you can create value, this episode shows you where to look: where values themselves are shifting.

In this episode of The Engineering Passion Express, I take you on a 100-year journey from open surgery to surgical robots through three lenses: First, a sick man in 1910 traveling to New York to pick the right surgeon. Second, Dr. John Wickham, who coined 'Minimally Invasive Surgery.' And finally, Fred Moll, who founded Intuitive Surgical, who along with a team of engineers brought surgical robots to the forefront.

Join me and learn how many times before an invention comes along, the values of an industry need to shift to make it the right time for the adoption of the technology to be a benefit. 

Transcript

SPEAKER_01 0:18

You're on the train to find a surgeon. Like those guys who use the engineered robots invented to cut you open and fix stuff inside you? You don't know what a robot is. What year is this? 1910? Yikes! We must have really switched to the wrong track somewhere along the line. Oh well, we'll let you out here. We'll catch up with the proper timeline and the invention of those robots later. See you in the future, and enjoy the New York of 1910. I step off the train and I look at my watch. It's been ten days since I left on the journey from Texas to New York to the minute. I was seeking a surgeon, and the journey was long and arduous. I've had the fear of sinking in a riverboat, being robbed on a train, and I've spent a fortune of time and money all while being sick to get here. Surgeons of the 1910s have reputations built from newspaper and radio, but that's not necessarily the same as surgical skill. I braved all that on the journey to New York because that's where people say the best surgeons are. On its surface, that could be entirely false. There are a few things that indicate there must be good surgeons here. One, there's a big population. Lots of people means lots of sources of talent. Two, there's money. And if you're skilled and you like money, you're seeking that. And three, there's a reputation. And that reputation draws in those looking for talent, and those customers draw in the talent. A virtuous cycle culminating in something that started as a possible fiction, becoming a truth if the reputation persists long enough. Now that I'm here, New York City feels louder than it needs to be. Carriages, horns, voices layered on top of one another. Brick buildings rise too close together, as if even the streets are competing for space. Everyone seems to be in a hurry, including the men in white coats, indifferent to the sick old man trying to find a hospital in a crowded city he's never been to. Of course this city is loud. Everyone is selling something. Being louder than the other guy is the way some people, like the newsies, for example, survive. Inside the hospital, the smell hits first. Chloroform, antiseptic, something sweet and chemical that makes it hard to tell whether this place exists to heal or to harm. I sit on a wooden bench, hat in my hands, watching names move through the building before I ever meet them. Names whispered by porters, names printed in newspapers, names repeated with confidence by people who sound like they know what they're talking about. One surgeon, Lawrence Ashford, is famous. His reputation even arrives before he does. I hear about his confidence, his decisiveness, the speed with which he works. While another surgeon, Samuel Smith, blends in. Dr. Samuel Smith. A name that doesn't announce itself. No stories trail behind him. No one lowers their voice when they speak his name. Dr. Ashford and Dr. Smith, they both seem capable, they both seem calm. They both wear the same coat. But I don't really know how to tell which one is better. How does someone make a life or death decision? Based on reputation, when skill is what matters. No charts line the walls. No numbers are offered. There is no ledger of outcomes, no public record of who lived cleaner lives afterward and who did not. There is only reputation. And reputation is unevenly distributed. I notice how people stand straighter around Dr. Ashford, the famous one. How his answers to questions are shorter, and how doubt seems unwelcome in his presence. With Dr. Samuel Smith, the questions linger longer. He listens more. He answers carefully. Seemingly competent, seemingly thoughtful, but seemingly isn't certainty. And my life is on the line. I make my guess. It's not a decision. Those require weighing out facts. There are none of those here. As they prepare me for surgery, I wonder if I've chosen wisely. As the mass lowers, the smell of chloroform thickens, and who knows what happens next. I have no idea how we've arrived in London. In this place, in this time, you can feel that the values of people are in plus. I'm sure the ships will in the history. We'll see it when we get fully back to the correct timeline, I'm sure. All you've done is get off the tree. The hospital's just around the corner, and it's time you see your patients. No more waiting. Gibble, gibble, gibble, gibble. It's the kind of smell that grows on a man after thirty years. The smell of familiarity. After being paged, I enter the room. A patient rests quietly. Sheets pulled to the chin, John Wickham hovers nearby, checking the chart, murmuring notes to himself. My eyes are scanning the patient and the chart. Dr. Wickham points to a column of data that I haven't seen before. What is this? I ask. I've never tracked these numbers before. Wickham glances at me. Recovery times. Complications that don't appear on mortality stats. Measures of trauma we can minimize. I've spent decades optimizing for outcomes. The ones the industry rewarded. Mortality. Obvious complications. Textbook recoveries.

SPEAKER_00 7:27

What was Wickham trying to do?

SPEAKER_01 7:30

So I ask him, and you care to measure these things? Why? Wickham smiles faintly. Because patients care. If we can shorten the time it takes to return to their life, isn't that what matters too? I look at the numbers again. Unsure. I don't have these numbers tracked for my patients. Do I need them? Back in my own office, Jack, my next surgical consult, is asking me questions. Your mortality rates? He asks. I present my record. Decades of experience, a steady hand, results that have stood the test of time. The patient nods, appreciating the history and data. I do nothing without multiple opinions, Jack says. That's wise, I tell him. Many patients return after other consultations because my experience carries weight. Later, as I walk past Wickham's office, I notice that he's speaking with Jack. Wickham's voice is calm, precise, careful. He's talking about his own mortality statistics. Slightly higher than mine, but still within safe ranges. Then he moves on to what no one else has measured. My focus is recovery, Wickham says. On average, patients return to normal life two months faster. Less pain, fewer complications that linger beyond the hospital. This is what matters to you, isn't it? The patient listens, eyes widening. You can tell for the first time he imagines life after surgery. Not just survival. His questions about mortality fade into the background. He is drawn to the life he could regain. Not just the life he could keep. Down the hallway, I continue eavesdropping. My chest tightening slightly for some reason. I've been in the upper echelons of surgical prestige, yet here a younger surgeon, less experienced in years, is teaching the patient about things I hadn't considered. Ignoring most of the hellos and Dr. Hawthorne attempts at my attention, my mind is fixated on these new metrics. They don't seem right to me, and I can't seem to focus on anything else at the moment. I reach the hospital administrator. I'm not sure what came over me, but I forgot to even knock. Instead saying, Do you know Dr. Wickham is tracking statistics no one else in the industry measures? And he's sharing them with patients to draw them here. The administrator raises an eyebrow, the kind of look you often see from administrators and bureaucrats who don't understand your technical concerns. Yes, and it's wrong. We've tracked mortality rates for decades. If optimizing these new metrics starts to affect those rates, or even just appears to, what will happen to the hospital, to our doctors, to our reputation? The administrator leans back. Dr. Wakeham is trending in the right direction. His mortality rates aren't rising. In fact, he's improving outcomes. Why is this panic necessary? I slammed the desk. Because it's uncontrolled. We built a hospital with prestige on mortality rates, and now he's rewriting the rules. The administrator remains calm, unconvinced by my fear. Most administrators are fed doom and gloom reports all day long. So they're like an impenetrable wall when it comes to emotional pleas. Perhaps it's time the rules reflected what patients actually care about, the administrator exclaims. Since mortality rates started as a measure, everyone has worked hard at making theirs exceptional. It's now hard to stand out as a hospital on that alone. We need something else to bring patients here. Rather than choosing to just go to their nearest hospital. In my opinion, Dr. Wickham is on to something good here, and his work is leading to lower costs for the hospital too. Less readmittance, less blood transfusion cost. I leave flustered, my chest tight, my mind racing. Am I a relic of the past? Is Wickham the future? Is my career hanging in the tension? It's been ten years since that day in the administrator's office. My career has reached terminal velocities since that day, and I've become a dinosaur. Dr. Wickham, on the other hand, is a star. He coined the term minimally invasive surgery. He's opened an institute to train others, creating culture where patient-centered measures drive practice by tracking data that matter to patients, not just what the industry measured. He has reshaped surgical priorities. And following that shift in value, he's reshaped the techniques that are used. Laparoscopic surgeries guided by cameras are now the norm rather than open surgeries. Training programs integrate these new methods. Mortality rates remain excellent, but recovery time, patient comfort, and long-term quality of life have become metrics surgeons cannot ignore. The field itself has bent. Most experienced practitioners are following reluctantly towards the values Dr. Wickham has championed. In fact, I'm stepping on a stage to present to a medical conference. Fifty surgeons seated in a medical theater designed for knowledge share. I've reached the tail end of my career and I have some lessons for those with decades left to go. Up on the stage, I begin my talk, opening up the conference where Dr. Wickham will speak later. While I'm a bit envious of Dr. Wickham, I'm also humbled that even though he was my junior and relied on my expertise at the beginning of his career, I had a privilege of working with a man who changed the entire industry. The lights dim and my presentation begins. I'm Dr. Reginald Hawthorne, 40 years as a surgeon. I should have seen this coming. I've been a doctor for decades. I've seen the evolution of surgical practice, recovery care, anesthesiological developments, diagnostic tooling developments. Nothing stays the same in this field forever. It's likely I should have been the one who saw what Dr. Wickham saw, and perhaps I did it one time. I just didn't care enough to experiment, to be a champion for the patients, and then once I had my data, campaign it across the industry. Dr. Wickham did. In fact, it's likely because I was focused in the wrong place. I was spending most of my available time honing my hands further, trying to make them legendary. Unfortunately, due to my bullheadedness and not realizing there is a plateau on the mortality metric beyond which hands have no further influence, I spent decades focused on the wrong problem. Rather than my hands going down in the history book as a surgeon, Dr. Wickham will be known as the man who changed surgery. Focusing on getting us all to understand, for two doctors with the same mortality rates, the one who has patients recovering the fastest is the most skilled. He's an admirable man, Dr. Wickham. You all are in attendance to hear from him, and it's my great honor to open for him. But before that, I want to share something honest with you. Years ago, before all of this caught on, Dr. Wickham was working on this alone. When I found out about these metrics he tracked, I was distracted and I was upset. My mind wouldn't get off of why. My frustration all those years back is gone. I'm too old to change what I focused on. However, I would let this be a lesson to all those pursuing fields like medicine. Values shift. Keep your eyes open on ways to do things better rather than following the same metrics as everyone else. If you hear of a doctor doing something that gets you fixated, angry, or otherwise emotional, sit with it longer, calm down, rationalize, try to understand whether they are correct. I didn't do enough of that. Dr. Wickham is an anomaly, a man so focused on how to do things right, to track things that matter to patients, yet also a risk taker and a change maker. This industry needs less Dr. Reginald Hawthorns, and it needs more Dr. John Wickham's. And that was it. I stepped off the stage, considering it an honor to even be in the same event with my protege, my colleague, my friend, John Wickham. Dr. John Wickham. And that was the last bit I ever contributed to the medical field. I couldn't help but wonder who out there is the next Dr. Wickham. And how could they possibly change this field in the same way? Well, we've arrived in California in the 1990s. I'm not sure how we keep bouncing around like this. We need to get all these train lines fixed. Anyway, we're drawing we're in the top of the digital age now. Computers, robots, it's changing everything. Every business magazine is full of this stuff. Oh look, we've arrived near another hospital. Anyone heading there for work? Please head out now. The hospital looks different than it used to. I used to work here as a surgeon. Dr. Mole, the patient is ready to see you. That used to ring a familiar sound here. The walls are smoother now, less color, less ornament. Technology hums everywhere. Monitors, carts, elevators. But the place still smells the same. Clean, sharp, faintly metallic. I've been here before. Excuse me, Fred. Yes, I respond. They're ready for you now. I'm nervous. These people used to be my peers, but now we feel opposed. I take the stage and start the presentation not loudly, not forcefully, but carefully. These are smart, educated, dedicated professionals who have spent decades honing their craft. They won't take likely to change without reason. I'm here to describe the work of my company, Intuitive Surgical. We're working on building surgical robots that help surgeons become superhuman in their hands abilities. This presentation is to give a state of technology. It feels like there are 50 of them in the room, all peering into my soul, and I feel a bit weak, but I continue anyway. My name is Fred Mole, the founder of Intuitive Surgical. I'm a former surgeon who saw an opportunity for technology to augment surgical abilities. I left my role as a surgeon and became an entrepreneur. I raised funding, hired engineers, and guided by my experience as a surgeon, we built robots to help surgeons make cleaner incisions, have safer operations, and provide quicker recovery for their patients. Here's how the robots work a culmination of multiple different technologies. First, our engineers worked on tremor filtering. Every involuntary movement is detected and removed. Only intentional motion passes through. Next, they built micro motion scaling. Large hand movements become sub-millimeter actions inside the body, granting precision beyond what normal hands can do. Then we worked on having articulated instruments, ones that can operate at angles the human wrist can't reach without massive strain. And then, of course, we've been worried about redundancy and fail-safes. If something goes wrong, the system stops before damage occurs. Surgeons all listen, but then then they resist. One surgeon doesn't raise his hand to his voice. He doesn't need to. His reputation fills the room before he speaks. He says, My outcomes are excellent. What he doesn't say, I don't want to relearn my craft. I don't want my advantage diluted. I don't want a machine standing between me and my identity. What he says instead?

SPEAKER_00 21:47

What happens if it fails inside a patient?

SPEAKER_01 21:51

I again describe the fail safes that I had just mentioned moments earlier, but it doesn't seem to be getting through. Perhaps because they don't care to hear it. The surgeon nods and then says, I don't see the problem that you're solving. And that's the end of it. They are all busy and they decide to go back to their planned operations, office hours, and normal day-to-day stuff. How could they not see the problem? Patients want small incisions, quick recovery, few complications. None of them see that? I was them. Am I really so different? I leave the meeting and go back to my teammate at the intuitive surgical headquarters. We refine the pitch, clarify the message, and adjust the language. Weeks pass. I meet another group of 50 or so surgeons. Same objections, different phrasing, exactly the same outcome. A committee wants more data, an administrator wants liability frameworks, marketing reframes the pitch, engineering iterates the system, money goes out, nothing comes in. Two months later, my financial investors ask, How are we doing? I have no answers that they want. Only that understanding of the market has improved. Which it has. But unfortunately, actual interest in the product has not. I asked for more time. They're obviously frustrated, but creation enough to provide more funding to continue. I go home that night, the looming failure weighing on my soul. At these conferences, it seems like the largest egos speak for the entire group, and I'm not certain whether their words are representative. I decide to meet with some surgeons one-on-one. And some ones which haven't heard about the technology yet. The initial meetings with the conference attendees aren't fruitful. It appears the opinions have been painted by the group already, aligning with what was already stated at the conference by the singular most vocal surgeons who resist the robots. But then there's Dr. Alvarez. My team had called his office and he was interested in talking because he likes to keep up with the technology. I do some research on him. His hands are steady, reliable, not legendary. I give him the same explanation as the conferences. Word for word, I talk about tremor filtering, micromotion scaling, articulated instruments, redundancy, and fail-safes. At each technology introduction, Dr. Alvarez leans forward and asks questions. How does it distinguish between a tremor and a small movement? Can the scaling be changed, or is it a set number? What sort of range do these articulated instruments have and what are their applications? The fail-safes are the most important. Make me feel good about them. Dread and fear race over my body. It seems like more of the same. I explain the fail-safes again, but then Dr. Alvarez says that's great. I realize these are not objections. They're invitations to say more. Dr. Alvarez asks about where he can test out the machines and get some initial training. I tell him we can set something up at the intuitive surgical headquarters for him to try it out and get trained. It's small, but it's something. Finally, 1% interest and 99% resistance. And that's enough to keep me going through all the fear. But I'm busy and there isn't much point in doing so if the hospital won't bring on one of your robots. I'd like to introduce you to the hospital administrator. Her name is Margaret Caldwell, and I can get you 15 minutes on her calendar. I appreciated that message from Dr. Alvarez. So I show up to the meeting early and I get my presentation ready. But Margaret isn't interested in surgical hands and the comparison to robots. She asks, What happens if the machine fails? Who carries the liability? What problem are we actually solving? I explain about fail safes. I don't have an answer about liability, but I'm happy to put in a legal framework that protects us both, as well as provide training to ensure staff use it properly. As for the problem, I tell her patients value, quick recovery times, small incisions, and precise work. She listens, raising an eyebrow like administrators often do. Then she delays. She says she liked to run it against committees, reviews, and budgets. I leave. Getting in my car, I stare at the wheel and droop my head. I've blown it. I didn't give that administrator anything to make a decision on. So they deferred again to surgeons, and we're back in the same loop. More months pass, more money burns. I have no idea what to tell my investors at this point. I certainly didn't reach out to them proactively to deliver any news. The vinyl chairs are dull green. One has a crack down the middle. Taped over so many times it's no longer clear what color it was originally. The lights hum. A cleaning cart rolls past. I used to walk these halls with certainty. Dr. Mole, the surgeon. Now I wait in them. Feeling the same uncertainty as the people waiting for the news of loved ones' operations. The stakes are different for them and me, but the butterflies in my stomach feel the same. Across the room, families sit the way families always sit, folded inward, eyes fixed on doors that won't open. No matter how hard you stare. I know this posture. I've seen it from the other side. And the thought races through my mind. I could stop. I could go back. Operate. Be certain again. No one would blame me. This entrepreneurial path was always fraught with peril. But then I think about those families and why they're here. Those people over there don't look happy. When Papa comes out of surgery, even if successful, he's not gonna be himself for a while. That's why waiting feels endless. That's why outcomes matter. And Dr. Alvarez suddenly pops into my mind. His questions, his curiosity. He's a like-minded doctor who wanted to surpass his physical limits for the benefit of his patients. He was my 1% hope. If he hadn't shown something to me that day, this would be the end. But hope never arrives as certainty. It arrives as interest in a possibility. And that interest sparks refusal. A refusal to quit.

SPEAKER_00 30:05

So I'll stay at it. But I need a boost.

SPEAKER_01 30:11

I'm gonna call Dr. Alvarez again. So I type in his digits, but he's unavailable. Though he returns my calls a couple hours later. He says, Margaret told me the hospital can't justify the cost of your surgical robots. I think she doesn't know how to value the technology correctly. I tell Dr. Alvarez, there's no doubt I let you down there. I was talking surgical in that meeting. If I could get another 15 minutes with her, I'd talk about shorter stays, less blood transfusions, lower 30-day readmissions, less complications, and mortality rate improvements. That would be better. I'll get you 15 more minutes, Dr. Alvarez tells me. I say, trying to keep it casual to help my brain remember, not to get technical, but to talk more about benefits to the hospital. What has changed since the last time? She asked me. Last time I was in here, I made a mistake. I told you about the things that matter to surgeons. Of course, you deferred me to them for further review. Today I'd like to quickly run you through why you should value these robots through the lens of the hospital as a business. That would be great. I know we have to be technologically forward here at the hospital, but I get pitches that I don't know what to do with on the daily. Please go ahead. There are really five things these robots will improve for the hospital. Shorter stays after surgery, less blood transfusions due to smaller incisions that cause less blood leakage, lower 30-day readmissions, less complications due to the precision offered by the robot and the minimal exposure of the patient, and as always, the important mortality rate improvement. Those are certainly items we're interested in. Each of these increase our cost of patient care. If you can provide some numbers of expected changes in these categories, we can run it against our expected savings and see if it makes sense. I'd be happy to. I'll send them to you tomorrow. Can we meet again next week to review those numbers and see if they make any sense? I'd be happy to. Thank you. Looking forward to talking again in the future. Me too. Have a great day. We agreed that while the hospital may have some uncertainty in the numbers, they could also do a massive press release and get some positive exposure for the hospital by being forward-thinking about technology. And that was enough to persuade Miss Caldwell to take a leap. Obviously, due to his interest and support, Dr. Alvarez adopts first. His incisions shrink, his recovery times shorten, his patients go home earlier than expected. Those patients tell the others they know who are seeking surgery about their experience. Other hospital administrators notice this. Hospitals start marketing it as a service. Demand appears where resistance once lived. The legendary surgical hands don't vanish, but they're no longer the ceiling to a great career for people like Dr. Alvarez. The robot doesn't replace surgeons, it changes what skill means. The floor rises, the ceiling stretches, and the industry can't ever go back. As I sit waiting, now I realize something. Every era thinks it's reached the end of replacement, that nothing else could possibly matter more. We had reputations, then we had outcomes, now we have precision. Then somebody asks a different question. So now I wonder who's sitting alone right now in a waiting room somewhere, refusing to quit, measuring something that no one else is ready to care about yet, and thinking about the new tools and innovations that will matter, and we'll be able to get the body.