In the early part of the 19th century, English craftsmen feared that their jobs would be lost to machines that were being used to manufacture textiles. Some of the workers who advocated destruction of the hated machines organized themselves into bands and swore their loyalty to King Ludd, probably a mythical figure. These followers of King Ludd came to be known as the Luddites. Although they proposed the destruction of property, Luddites rejected violence against people and enjoyed considerable support in their communities. Starting in Nottingham in 1811, the followers of King Ludd, usually masked and working at night, began rioting and dismantling establishments that were using new technology. The Luddite movement rapidly spread to Yorkshire, Lancashire, Derbyshire and Leicestershire. In 1812, a band of Luddites threatened the property of an employer named Horsfall who, in turn, had them shot. Horsfall was later killed in reprisal and the government of Robert Banks Jenkinson, second Earl of Liverpool, decided that enough was enough.
Severe repressive measures were instituted against the Luddites, thereby resulting in a mass trial at York in 1813. Many of the Luddites were hanged or deported, and the organization withered. The depression that followed the Napoleonic Wars resulted in a rebirth of the movement, but legal repression and a reviving economy eventually led to the dissolution of the Luddite bands.
Twentieth Century Luddites
Today, the term Luddite is applied to those who reject technological progress. Indeed, anyone who questions the value of the latest technological innovation runs the risk of being labeled a Luddite — and a Luddite is definitely something you don’t want to be. The term carries with it the connotation of hopeless resistance against the inevitable. It conjures up the picture of a pitiful, benighted creature facing a future for which it is poorly prepared. None of us want to get behind the curve and find out that we no longer have a future. Because of our desperate fear of being labeled Luddites, we run the risks of acting like lemmings.
The Lemming Factor
Lemmings are small rodents belonging to the family Cricetidae. They are found primarily in the northern temperate and polar regions of Eurasia and North America and are divided into four genera: Dicrostonyx, the arctic lemmings; Myopus, the red backed lemmings; Synaptomys, the bog lemmings; and Lemmus, the true lemmings.
Lemmings are fetching little creatures five or six inches long with short legs, small ears, a stump of a tail and long, soft fur. They are herbivores who feed on roots, grass and other shoots. They also are prolific — breeding from spring to fall with a gestation period of 20 days, and up to nine lemmings per litter.
What sets the lemming apart from other rodents are their regular fluctuations in population density and their periodic migrations. For reasons that are poorly understood, the true lemming suffers from population explosions every three to four years.
When a population explosion occurs, lemmings begin to move from areas of highest population density. The migration begins furtively at night, but as the number of migrating lemmings increases they become bolder and move throughout the day. The migration will often follow roads made by people or other animals.
Lemmings are not suicidal. They hesitate to enter water and will look for means to avoid swimming. Nevertheless, in the case of the Norway lemming, many of the migrants follow the pack over cliffs and into the sea. No one knows why the lemmings continue on to death by drowning. My bet is that some influential lemmings have told them that the wave of the future lies just over the cliff, and they don’t want to get left behind. If we could understand lemming speech we might hear them muttering “minimally invasive,” “neuroendovascular surgery,” “endoscopic,” and “image guided” as they took the plunge for their terminal sea bath.
Neurosurgeons need to avoid being lemmings as much as we need to avoid being Luddites. It is likely that some innovative approaches in neurosurgical care offer solutions to clinical problems that improve patient care and/or reduce cost. We would be Luddites if we avoid a new method of treatment because we already know how to treat the problem. It is equally likely that some of the neurosurgical innovations will prove to be very expensive without improving patient care.
We are lemmings if we follow the latest fad simply because we are afraid to get left behind. Therefore, neurosurgeons need to critically evaluate new technologies emerging in the medical arena. Outcomes studies in neurosurgery will make this evaluation process easier.
Importance of Outcomes Studies
Outcomes research is a relatively new field, or intellectual endeavor, which seeks to rigorously evaluate the effectiveness of medical care from a patient- and community- oriented standpoint. Methodologies that exist within the field of outcomes research allow us to evaluate new technology and its impacts on the effectiveness of our medical care.
For example, a case control study to ascertain whether any benefit accrues to patients from the use of image-guided techniques for the neurosurgical treatment of gliomas would be of great value. If, as the advocates of such technology maintain, image-guided surgery makes procedures safer, faster and more cost effective, then it should be possible to perform a case control study to document this. A prospective, randomized study would not be necessary.
Rather, a control group with patients matched for age, location, size and grade of tumor, and adjunctive therapy could be compared to the image-guided treatment group in terms of postoperative neurological status, functional health status, resource utilization and duration of survival. Group size necessary to assure adequate statistical power can be determined prospectively. The results of such studies largely impact the medical community.
The application of outcomes research could have a profound effect on the practice of neurosurgery. The claims of technological advances need to be evaluated with the same rigor as other hypotheses. In this way, neurosurgeons can avoid the fate of the Luddite, who thinks it is highly unlikely that a new technology will improve care, only to find out later, that he was mistaken. We also can avoid the fate of the lemming who, mesmerized by proponents of the latest technological marvel, fail to see the precipice.