31.1 Introduction

The adoption of any new technology requires navigating an initial learning curve prior to attaining mastery of the new technique and its adoption into routine practice. The learning curve can be defined as the time (or in the case of surgery, number of cases) it takes to attain a reproducible and steady level of mastery of a new technique or technology. Surgically, this translates into reaching a state with the lowest possible complication rate and shortest case length attainable to achieve that rate. Surgical techniques/technologies vary in their relative ease or difficulty of mastery based on various factors including technical difficulty, resources necessary, need for specialized training, etc. The learning curve for a procedure is typically referred to as steep when a procedure is thought to be difficult to master or incorporate into regular practice. However, graphically, a steep learning curve is actually desirable as it indicates a smaller number of cases to attain the highest attainable competence (see Fig. 31‑1 , Fig. 31‑2).

In surgery there is an inherent tension between adoption of new technologies that eventually make treatments safer and more effective and navigating the learning curve for those technologies as they are being adopted. ^{1 ,​ 2} The difficulty with the surgical learning curve is that while on the slope of the curve a higher complication rate is typically identified, and this can translate into patient harm. Due to the ethical primacy of “primum non-nocere,” or first do no harm, it is difficult to accept performing a new procedure that may take longer or carry a higher complication risk initially than the gold standard a surgeon is more familiar with. In fact, governing bodies have stated that there should be no learning curve in surgery when it comes to complications. ^{1 ,​ 2} However, it is widely acknowledged that all new techniques/technologies have some learning curve associated. Given the desirability of adopting technological and procedural advancement, and given this adoption comes at an initial cost in inefficiency and increased complications, it is of paramount importance to understand the learning curve and to identify ways to steepen the curve for rapid and safe mastery of new technologies. This chapter will discuss barriers to adoption of new technology in spinal surgery, examine the learning curve for new technology in spinal surgery, and discuss potential means to steepen the learning curve for new techniques/technologies in spinal surgery.

31.2 Barriers to Adoption of New Technology

Prior to considering specific mechanisms to steepen the learning curve, it is worth considering the barriers to adoption of new technologies, since mounting the learning curve to begin with depends on the decision to adopt a new technology and since barriers to adoption can cause providers to fall off the learning curve entirely.

Barriers to adoption typically fall into two categories: (1) factors associated with the technology itself and (2) contextual factors surrounding the technology to be adopted. ³ Factors associated with the technology itself include a perceived difficulty of use, cost to the system, surgeon investment in time/energy learning the new technique/technology, and lack of perceived volume of cases or appeal to patients and providers. ^{3 ,​ 4} In the case of robotics/navigation, direct costs to an institution can be in the six or seven figures and in the case of at least one of the manufacturers of robotic technology for spinal surgery, surgeons must travel to company headquarters to receive onsite formal training prior to being certified to perform robotic spinal operations. Contextual factors include the perceived benefit of a new technology versus existing technologies, patient desire/appeal, evidence for superiority established in the literature, marketing by companies, and adoption by surgeon or thought leaders/local competition. ³ While some of these barriers are difficult to alter or influence, such as the direct cost of the technology, others are more amenable to intervention—particularly study of a new technology.

When a new technology that is at face value appealing also has a compelling evidence-basis for its use in the literature, its adoption is more likely, as it is eventually seen as a standard of care and surgeons/institutions would lag behind peers if the technology is not adopted. ³ While technology in healthcare and spinal surgery in particular continues to progress rapidly, and its study is welcomed and necessary, its assessment continues to lag. ⁵ One of the reasons for this is described as Buxton’s law. ⁶ This asserts that a new technology is too new to be studied until it is too established to be studied. ⁶ This means that there is a reticence to study a new technology, while early adopters are on the initial slope of the learning curve for fear that the promising technology, which may be of significant benefit once practitioners reach the asymptote of the learning curve (the point of maximal efficiency and minimal complication risk), will fare poorly against established procedures. However, once such a new technology has achieved widespread adoption, there is a further lack of desire to study it, given that practitioners believe they would now be delivering less than the new standard to revert to the established procedure. As such, many new technologies have not undergone the rigorous study that would typically be required to establish them as superior to established procedures and as new standards of care. ³ The extent to which a new technology can be studied rigorously to establish equivalency and hopefully superiority compared to established techniques is an important factor in prompting surgeons to more quickly adopt the new technology to remain on the forefront of surgical technology development and not be left behind by advancements in the field. Ideally, a new technology would be studied both on the slope of the learning curve and at the asymptote, to both understand risks/complications while on the curve and define the learning curve, in addition to establishing equivalency/superiority compared to established techniques once the asymptote for adoption of the new technology has been reached.

In summary, new technologies face multiple barriers to adoption, both inherent to the procedure and cultural/contextual. Some barriers are more amenable to intervention than others. In short, providing a solid evidence basis for a new technology, making the technology as cost-effective as possible, minimizing time/energy expenditure by the practitioner adopting the technology, and fostering a supportive cultural environment for adoption of promising technologies help overcome these barriers.