Neurosurgery, Technology and Motivation to Change
Dr. Wouter van Furth is a neurosurgeon at Leiden University Medical Center in the Netherlands who is interested in better clinical results with the help of evolving surgical techniques and technological advancements. In this episode he shares information on the education and healthcare systems in the Netherlands, medical technology breakthroughs and challenges in neurosurgery, breaking habits and the difficulty of change, why education when any change to a device is critical, and a burning question he asked the Mastering Medical Device community to explore.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome. I'm excited to bring you today's episode for a couple of reasons. First, our guest, Dr. Wouter van Furth brings us some great information about his neurosurgery practice in the Netherlands. And second Wouter's a listener to the Mastering Medical Device podcast. I learned about him when he sent me an email with a question that he had. Then I went and set up a ZOOM call with him to dig deeper into his question and discovered he's he would really make a good guest. And also his question is one that I think we're all interested in. And we're gonna be digging in to it in this episode, as well as next week's episode. The reason I'm so excited about Wouter reaching out with the question is that as a podcaster, most of your listeners Listen, but don't engage. I get it. I listened a lot of podcasts too. And I'm a passive listener with some of them. But I'm also an engaged listener on others and have reached out to the hosts and said thanks, offered suggestions or left them a rating. I'd like to ask you a personal favor because I think these podcasts are better served. Or everyone's better served with a podcast when it's more of an engaged audience. So what I'd like you to do is send me a short note with a topic or the type of guests that you'd like to hear from, and then I'll do my best to deliver. You'll find my LinkedIn address in the show notes. And you can connect with me there and attach a quick note. I really appreciate all of you listening. And if you just want to listen, that's fine. But I'd also really appreciate it if you could reach out to me. And for those of you who already have. Thanks so much. As I mentioned, Wilder is a neurosurgeon at Leiden University Medical Center in the Netherlands. He earned his MD from Utrecht University. And you'll also hear he has an entrepreneurial side, having founded a company called suture aid. One of the things I really enjoyed about this conversation is that at certain times, I thought I could actually hear him think we got into some really interesting areas. And his self reflection said a lot to me about his openness and willingness to learn. And those are two traits I really hold in high regard. We got into the Dutch educational system, healthcare system taxes, medical technology, challenges and neurosurgery. And the question that he asked me, and I'll let you hear directly from him about what that is. Here's our conversation. Walter, welcome.
Wouter van Furth, MD 03:17
Hi, Pat.
Patrick Kothe 03:18
So to get us started, I'd like to find out how you became interested in being a physician. And why you chose neurosurgery.
Wouter van Furth, MD 03:28
Being a physician was a bit of a family tradition. So my grandfather was already a doctor, a father was a doctor. So it's kind of almost expected of me, my brother or a sister went into the medical field. I wanted to go somewhere else. So I started to start out with a psychology, but ended up doing medicine as well and then did psychopharmacology for a PhD. So I was already doing brain surgery in rats for my PhD thesis, and noticed that I enjoy working with my hands. When we did the internships. It was either neurology or neurosurgery. And I became aware of a surgical personality. I think it's a personality thing. So it was neurosurgery.
Patrick Kothe 04:13
So what do you mean by it's a personality thing?
Wouter van Furth, MD 04:17
The theory of Neurology is wonderful how the brain works and how you can assess that. However, the practice is, is tedious. You know, you're behind the desk thinking. A surgical personality is much more of action, of chaos of unpredictability. I enjoyed being in the ER having you know, everything hit you at the same time, and you have to kind of make urgent decisions. And the O r as well. It has a level of stress, but it also has a little level of focus. So I think it really has to do with personality.
Patrick Kothe 04:50
I think that's interesting because I I spent the first two years of my medical career in the pharmaceutical area and discovered very quickly that that was not My personality, I was more of a device person. We had a, we had a joint venture with with another division of a large company that had a device. And I really gravitated towards that. And I felt that that was my personality, I was more more of a device person than a chemical, chemical person.
Wouter van Furth, MD 05:18
Yeah, there you go. personality, this, this determines a lot of things.
Patrick Kothe 05:23
So what are what is the educational pathway for a physician, if could you kind of give us a good idea within another lens, what the educational process looks like?
Wouter van Furth, MD 05:36
So in the Netherlands is a little different from in the States, we have a high school, which takes six years. So the typical students after high school is 18, they go into university, you can go directly into med school, so you don't have to go for undergrad or something, which is another six years. And in those six years, you have a year and a half or two years of internships. And then you have to get into a residency program. This can be quite hard. So this those numbers are limited. For instance, in neurosurgery, it's in the country, it's two or three places for the whole country. So there's quite a fierce competition for that. Once you're in, in the residency program, then it's it's basically you know, you have a job, almost, you know, it's there's some specialties now there's, there's some joblessness, but mostly, it's so well regulated, that we don't have an excess of specialties.
Patrick Kothe 06:31
In the state's medical school can be quite expensive, and it's not subsidized. What is the situation in the Netherlands,
Wouter van Furth, MD 06:38
it used to be fantastic. Like it's very subsidized. It's a little bit less subsidized, but it's still nowhere near as expensive as in the States. So there's a government funding for student, they can get loans with great rates. So and there's a probational payback. So if you're a student, I think if you end up doing loaning everything, you probably have like a 30,000 euro debt, but you only start paying back once you start earning money. It's a system that allows basically everybody to go to university, there's no there's no financial reason not to go to university.
Patrick Kothe 07:19
And that's whether it's University for engineering or whether it's university to be a physician, exactly. The training itself after you get to get through with your six years. You said you had two years of internship, what happens after that is is it residency fellowship,
Wouter van Furth, MD 07:36
basically, yeah, so most students are most MDS will not immediately get it accepted to a residency program for in training. So they'll have different jobs that work as a assistant cardiologist, for instance, but not being trained for cardiology, and but this will just help them experience get more practice. also find out what they really enjoy and what they what they won't, and build up the resume so that you know, at some point, they get accepted to a residency program for training, and then the six year start. So often, there's two or three years in between before you can actually start with your residency.
Patrick Kothe 08:12
Or some specialties are more in demand than others. What is it? What is it like in the Netherlands says primary care, less neurosurgery more? What does it INJAZ heart?
Wouter van Furth, MD 08:25
It's bad, it's hard for me to say, I've been in neurosurgery for over 20 years. So typically, I see a lot of people that want to become a neurosurgeon. I think still a lot of people want to become a general practitioner as well. My impression is that if you want to become a general practitioner, it's fairly easy. For neurosurgery it isn't. But for either cardiac thoracic surgery, it isn't either, you know, so there's some specialties that that are quite hard, because they're small, you know, there's, there's not so many people needed.
Patrick Kothe 08:56
So once you are done with your education, and now you have a position, you're not a neurosurgeon. Are you an individual person who's practicing? Are you part of a group? Do you are you part of the university? What does the practice look like?
Wouter van Furth, MD 09:14
In the Netherlands, the healthcare is very well regulated. So for neurosurgery, the hospital needs to have a permit, especially for cranial surgery or so shouldn't spine surgery, for simple spine surgery, you can do it in other hot places as well. But for the more complex cases, you need a permit. So there were only 17 hospitals in the whole country that have this permit. So if you want to do that kind of surgery, you need to join that group. Most of them are academics. So there's eight academic hospitals. The other ones are affiliated with the academic or they are in another kind of big organization, so to speak for, for hospitals. So they're all large hospitals, there's no tiny ones. So as an individual, you mostly will be in Not in the fee for service system, but you'll be salary. There's a couple of groups that are still doing doing fee for surgery, and they kind of run it like that.
Patrick Kothe 10:08
So you're working in a university. So I work in a university, you're employed by the university, and it's a it's a salary, salary position, it is compensation wise, is there anything based on results? Or patient satisfaction or efficiency? Is there anything tied to your compensation there?
Wouter van Furth, MD 10:27
Fantastic question. I wish it were is very frustrating. Within a university, you typically get acknowledged by your academic prestige, right. So if you write a lot of papers, you will at some point, you know, you get funding for your research, etc, you get acknowledged, and you may become professor and you heard a little bit more and, and have a bit more freedom in how you spent your time. If you're a surgeon, and you just do excellent clinical work. That's not particularly recognized as important. So there's no financial or other composition for quality of work for research output or anything. I've discussed this with my colleagues over over in the US, for instance, in Ohio State, and de, they have a very, you know, system that works with points and you can earn so much. And then you can if you don't have enough quality points, you will never go to another salary scale or something, which sounds great, you know, because you want to kind of emphasize that people should deliver great quality of care and kind of measured so that you can do something about it. We're not there yet. We're all equal so to speak. It's It's It's socialized medicine, you know, it's a that was it, it has its benefits, but it has his downfalls as well.
Patrick Kothe 11:44
So let's talk about socialized medicine for a second, every healthcare system out there has got kind of similar, similar issues, everyone wants to deliver the very best quality of care, they want to have the population covered. So universal care, and they want to do it as efficiently as possible for the least amount of of money as possible. What is the system like in the Netherlands, it's a pretty unique system. And if you could just kind of explain a little bit about how it came to be what it is,
Wouter van Furth, MD 12:21
we have socialized medicine, which means that everybody is mandatory to have insurance and insurance is relatively speaking cheap, they have to accept you, it's a legally bound system, that there's no exceptions there. So every inhabitant from the country has an insurance. If you for instance, any illegal immigrant, you cannot get an assurance. But if you have a severe disease, and you come to my or I'll treat, you just assume, and then behind this behind the screens, they will try to get you an assurance as if you had an insurance as a Dutch person, and it will still be paid for in general, we won't refuse people we will. And most of it will be paid for by the insurance companies. It's private insurance companies,
Patrick Kothe 13:07
but it's legally system is that they have to accept you. Do you know approximately how much people are paying for their insurance premiums?
Wouter van Furth, MD 13:19
But I believe it's about 1200 or 1400 euros a year.
Patrick Kothe 13:25
Okay, so that is your your premiums, if you have a catastrophic event, do you have any idea what people pay when you have a catastrophic event? And it may be 50 100 500,000 euros? Are they still just paying that's you know, 14 $100 per year? Or? Or do they pay over and above that?
Wouter van Furth, MD 13:46
No. So So you have your own personal risk. And so you can set that at a certain level. So of course, if you if you accept a higher rescue, pay less per year, but that's what you pay. And then so you don't have to pay anything additional in for this event. However, if you want to change insurance companies, another time after you had the event, the new insurance company may increase your premium or your because of the event and of the associated risk. So once you had it, it's it's wise to stay with this one insurance company.
Patrick Kothe 14:20
So in the US, there's a lot of debate on health care system that we have here, because there's a lot of people who are not covered. And the cost is quite substantial. And we've had debate year with government insurance, private insurance, mandated insurance, all of those different different things. So was it painful to you for the for the country to get to where it is today where it's mandated that everyone has to have insurance and that there's there's a system in place that's regulated,
Wouter van Furth, MD 14:57
and no, it wasn't said There used to be a system Where you had truly like social insurance by the government, and then you could have your own private insurance on top of it for the wealthy people, or the people who wanted to spend their money there, and that had an effect. So if you would go to the hospital, you could have a different department, which was only for private patients. So that was a bit more luxurious and et cetera, et cetera, I don't think you particularly would get better care. But you may be able to choose your doctor a little better. That's gone. So they they made one system and then within the system, you can you can arrange a little bit of your levels of care. So if you want to have extra dental care, for instance, you can insure for that. Or if you want to have physical therapy, not just five times a year, but Unlimited, you can say, Okay, I want to insure that for if I, if I need it, I can have that. So you have these options, but they're the same for everybody. So you can have a more luxurious packet, or you can be a bit more back to basics, but it's there's no difference. And I think it wasn't painful for the for the country, I think it was totally fine.
Patrick Kothe 16:07
Obviously, you have this type of type of system. taxes would go up if somebody's got to pay for it in some way.
Wouter van Furth, MD 16:15
So yeah, we pay a lot of tax. Yeah, so income tax is is huge. There's a system but it goes all the way up to 52%. And of course, now we have a VAT, which is a another 21%. And then we have your your your taxes for your home and whatever. So from every euro you make 75 cents or 80 cents go to taxes at some point.
Patrick Kothe 16:38
On the plus side everyone's covered are catastrophic issues. where someone is wiped out financially.
Wouter van Furth, MD 16:47
Yeah, it's a little bit from the US I think, is a lot of the things our government nationally does is is taken care of more regionally or even locally, in the USA, for instance, where you live in which neighborhood of a city is important for your taxes, but also for your schools, etc. In the US in the Netherlands, it's all taken care of by the by the government, but it's a small country, right? There's only 16 million people is relatively efficient. But we pay a lot of Texas but I do believe we get a lot of in return for the streets and the public transportation and the healthcare system. That's kind of all taken care of you don't need me to worry about that.
Patrick Kothe 17:23
So let's talk about neurosurgery and your patients. So what is your typical patient? What types of surgery
17:32
do you do?
Wouter van Furth, MD 17:33
I'm a neurosurgeon specialized in skull base surgery. So I do mainly cranial procedures. I've done until quite recently, also, a bit of spine surgery but never the advanced stuff. So no spinal fixations and stuff like that, just just a little bit of spinal fixations in the neck but but nothing lumbar, and just the basic spine stuff, and then mostly criminal cases. So, my normal days I do meningioma at the skull base and pituitary tumors. And then we have the more advanced cases like a Chordoma called rasa comas, which are rather rare but but we are a center where they accumulate so we do them every month or so.
Patrick Kothe 18:21
And how do you how do your patients come to you? How are they referred to you?
Wouter van Furth, MD 18:25
Of course, every hospital has its own kind of catchment area. So that's where the normal patients come from. And then because I've I've made a bit of a name in this particular area of endoscopic skull base surgery, I get some patients referred to me personally as well, just because they have a, you know, a complex case and they think this might be a solution for that.
Patrick Kothe 18:46
The types of surgeries that you do mostly open up and surgeries.
Wouter van Furth, MD 18:52
No. often enough, I do endoscopy scope assertion, which means that it's a it's an endoscope through the nostrils. Technically, it's endoscopy assisted. So we have an endoscope and we have surgical tools. And we go through the nostrils to the cranial base, and every sector to wear that way. So that's what I do mostly. Two out of three cases are probably then opened the other third.
Patrick Kothe 19:15
When did that change?
Wouter van Furth, MD 19:18
I started doing endoscopy in 2003. I did. scope is fellowship in Toronto, with Dr. Michael Cusumano, and he was one of the first pioneers in the world doing endoscopy. At the time, pituitary tumors were operated with a microscope, but he was a pioneer did with the end together as with the endoscope, so I was trained there. When it came back in the Netherlands. We thought about it I started doing some courses to get educated and trained as a team. And then in 2003 2004, we started doing our first cases. And that gradually grew first with a few cases just doing pituitary ease and I went to do more courses and more courses and We expanded our own experiences. And then I had a great NT partner, which is which is fundamental for this. Together, we build our experiences slowly and slowly, we could do more complex cases by now we we have enough volume to do a lot of those cases.
Patrick Kothe 20:19
And that 2003 2004 timeframe was endoscopy, new, or was it new to you?
Wouter van Furth, MD 20:26
It was certainly new to me. But it was new in the world as well. It also has been used by anti surgeons for a functional endoscopic sinus surgery fess. And there were some groups that were pioneering to also use it for other cranial base cases and introducing neurosurgeons most neurosurgeons were, of course, trained with a microscope. And so they they find it difficult to work with an endoscope, and there were only a few centers in the world, interestingly enough to have them in Italy, where they were the pioneers. And then in the States, in Pittsburgh, they separately kind of grew the volume. And then of course, he had some EMTs. In Austria, it was it was just a few places in the world where this was kind of growing. And this was also when we were wanting to do this, we went to Italy to learn from them. Because they had courses and they showed how they were doing it. And then I went to Pittsburgh. And so that's kind of the way you get trained to if you want to do something new.
Patrick Kothe 21:27
Let's talk about the technology associated with that, too, because I'm sure if it's early on technology was being developed at the same time. What was the technology, like when you started? And how did you see that develop?
Wouter van Furth, MD 21:40
The technology is still rudimentary, I would say it needs a lot of development, although were so many years further, and the scopes have improved tremendously, like fantastic. It's the endoscope that the pioneers used. It's if you see those videos, you go like really? Were you able to do surgery with that, because it's it's hard to hard to see anything.
Patrick Kothe 22:00
What's the big difference? Is that visualization?
Wouter van Furth, MD 22:03
Yeah, yeah, it's that has it. So it's illumination, it's it's also the quality of division. So it's a it's much more easy to see the details between the different layers of the tissues. I don't know if you remember going from a normal TV to an HDTV. But that's a huge difference, right? And once you've seen once you have two days of HDTV in your home, you go and you got to see somebody else with normally they're like, really, you know, is that what it looks like? It's the same here, right. And, and, and now we have Ultra HD and we have 3d endoscopy if you want. So there's there's many options now. But the quality of the visualization is as improved tremendous, the quality of the instruments to get there and to to be able to do surgery is lagging behind. And probably the market size is not big enough to to develop new, really innovative machinery, we can now see around corners, we can see the tumor in places where you couldn't believe that you could see it. But it's very hard to get there.
Patrick Kothe 23:11
Why do you think that instruments are, are not developed? Because there's different types of instruments in robotics or other areas that are that are close to this, which you think that they would import that knowledge and import that technology into into this application?
Wouter van Furth, MD 23:29
Yeah, I certainly would hope so. And hopefully, there's some listeners to the podcast, who think, Okay, this might be interesting, perhaps I'll go there. But in fact, almost the opposite is true. A very large player in this field, had decided last year to totally went out of scope of surgery and kind of go all the way in another direction. And this created a worldwide protest. And and they happily returned on that decision and said, Okay, we'll keep supporting it. But they were like a major player in this field. And they were all of a sudden going out of it. I think because it's not it's not a market that's growing fast enough. You know, it's a it's probably a relatively small sized market.
Patrick Kothe 24:17
What about robotics as robotics entered into your space?
Wouter van Furth, MD 24:21
Great question. Yes and no. So there's there are some robotic players and we all know them. And there's a single port robot that is now being used for trance Oral Surgery. And my good friend Jacopo delong, from Pisa, Italy. He's one of the speakers on a podcast series yesterday about this, so that it is being developed and it is going somewhere, but it's very still very experimental robotics could be a good solution, but it needs to be miniaturized the robotics that are now used for laparotomy so for surgeries of the belly, they use multiple portals, to Get in. And they're quite large. And and then if you want to do that with the head, you kind of miss the point, the whole idea is that we use the natural orifices. So we go either through your nostrils, we can go through your mouth, we can go through your eye sockets to go into the area behind it, typically skull base, sometimes even brain, but it allows you a different angle of attack. So now we come from anterior to posterior, and all the vital structures are behind it or lateral to it. So this is, this is the safest route to get to the tumor. While if you go from the sides, all the five structures are in your way, you have to go behind them or past them, which puts at jeopardy.
Patrick Kothe 25:43
As someone who was early to the game, so to speak with the this type of surgery, did you have a lot of interaction with the companies that were developing the technology? And did you provide any input?
Wouter van Furth, MD 25:55
Yeah, yeah, we did. And it was I was asked to get some input to put some input. And one of those companies is an American company, and they wanted me to fly over and do a cadaver session, etc, I found that time restraints are kind of putting a limit to this, the the visualization companies, some of them are European. So there's a little bit easier. That was kind of nice that those technologies for visualization have improved a lot. And, and, and every time you get new iterations, and you get to see them and try them out. So that was quite fantastic. Honestly, the instrumentation side of it, this has kind of, while limited, it's there's not a lot of innovation going on there. It must be difficult, because I know certain surgeons have tried to come up with their own companies and own devices to improve it and have failed.
Patrick Kothe 26:44
Let's talk about bringing new technologies into facility in the Netherlands. How does how does that occur? Is that it? Are these physician preference items? Are their purchasing committees? How does a technology get
Wouter van Furth, MD 26:58
brought into the hospital? All of the above it is a physician preference. And typically, the physician will ask for something and say, Okay, well, let's do this. And it used to be that we were allowed to do, basically everything we wanted. So I would have my own set. And with my own scissors, I still have my own sets. By the way, if you want to split, let's say they have a 3d endoscope, that that you really think you need, then you have to go to so I make the request, you have to go through an investment committee, you have to make kind of made the argument that this is really needed, and then it's had to put on a budget. So you won't get it this year. But you may get it next year. smaller items, I don't know a pair of scissors or you know, forceps or whatever, that's usually not a problem. We used to have, for instance, for sutures, everybody could have kind of have their own specialty that's gone. Now they they the hospital that that all goes again, for all kinds of rules, right? If the hospital has to spend a certain amount of money, I'm not sure what that where the limit is the cutoff point, then it has to be like a formal process where all companies can compete with each other and, you know, make an offer for the sutures.
Patrick Kothe 28:09
In many surgeries, sales representatives are allowed in operating rooms is that the case? With the Netherlands?
Wouter van Furth, MD 28:18
They are not so much sale reps. But But well, if let's say you do this by locates with instrumentation, then the rep from the company who knows exactly how it goes, he's elected.
Patrick Kothe 28:30
So how do you learn about new technologies?
Wouter van Furth, MD 28:33
Usually through word of mouth, actually, I've stopped going to the large meetings. Of course, with COVID. There's no large meetings anymore. But even before that, I stopped going to them because they're too big. And there's not enough new stuff. But the small meetings, the specialized meetings, and also, the teaching events that I go to this is where you learn from your colleagues that they have new technologies and that they tried something out that really works. And you're okay, I was I want to try that out as well.
Patrick Kothe 28:59
So when you say word of mouth, you're really talking about close number of close group of confidence that
Wouter van Furth, MD 29:05
you have within within the community. Probably what this is a niche, right. So this is this is a niche where the people that are mostly involved know each other, so so it's not so many people, so they know each other quite well. We get to see each other a few times a year. And so you get to share experiences about technologies and also about new techniques about new surgical approaches about you know, what's
Patrick Kothe 29:31
possible and what isn't. One new technology that you were involved with was a company that that you founded suture aid. Can you tell me a little bit about what that was all about and what the need was for that particular product?
Wouter van Furth, MD 29:50
Yes, citrate was a company as started years ago, because I had difficulties with suturing. I wondered about this, but there's an inherent problem. In the suture process is that you firstly use two hands one hand, you have a forceps to grab the tissue, the other hands, you have a needle holder to hat that has the suture in it, you go through the tissue, and and your needle has to kind of poke out so that you can regrab it right, you have to let go of it and grab it at the pointy end without damaging it to pull it through. So there's this moment of freedom of the needle, that may disappear on you, if the tissue has some some strength to it, it may disappear on you that you get an awkward situation Okay, how Where do I find it etc, etc, I thought it will be easier to have on your forceps, a reception area where the musical go in and get stuck so that you never lose control of a needle. And so you put this reception area against the tissue that you want to puncture. And you go with your needle through the tissue into the reception area. Once it's safely stuck there you let it go. And then ideally with the with the force if you put it through. So it also takes you know, have one less maneuver to do you don't have to regrab it, you just pull it out with the forceps and then immediately go ahead and you're putting your needle target. And another benefit we noticed was that in some tissues that is fragile, you have a phenomenon called tenting, which tenting is that the needle, even the sharp needle pushes the tissue a little bit, you know, forward forming a tent before it goes through. And if you do vascular surgery, this tenting can damage the vessel. So having something behind it to get counter pressure is beneficial. This reception area would allow that to do that. So for those procedures, it looked like a good product and make life a little bit easier and also faster. Right. And again, with faster surgery. Time is of essence. So we thought it was worthwhile pursuing.
Patrick Kothe 31:56
What did you discover, once you develop that product?
Wouter van Furth, MD 32:00
My main conclusion is that the problem that we wanted to solve isn't big enough, and it isn't big enough for a surgeon to change his habits. And even myself, I'm, you know, I'm a surgeon, I was the CEO of this company. I've tried out this product in cadavers, in animal models, etc. I was very convinced that it was a good product and that it would benefit, you know, our surgeries. But once in a real surgery, I used it. But sometimes it felt a little awkward not being used to this device. And it would fall back to my old habits. And I think we're so ingrained with what we do. And we know that we can do it safely. That as a surgeon, I'm a different person than I was as a CEO. I wasn't surprised for me that even I would have this difficulty in surgery.
Patrick Kothe 32:47
When you made the decision to develop it. Did you talk to a lot of people? Or did you just think I've, I've got the idea? I think it's a it's something here, let me let me go off and start building something.
Wouter van Furth, MD 32:58
Oh, no, of course, if asked tons of people and tons of colleagues, I mean, that's, that's the easy part. If your assertion and you're in the surgical community, right. And everybody kind of recognizes this problem. And it says, Well, that sounds like a good idea. And we tested it out, you know, we made a first prototype, you test it out on on some model, and you go like, yeah, this works this, this will be good. And then of course you played Okay, so would you use this URL? Use it? And would you buy it? Sure. And what do you think would be the cost? And you get some number, which is completely not, you know, not the truth. It's not the same? Once you have the product there and you go into the URL and say, Okay, now I have it, do you want to test it out? Well, perhaps tomorrow, and then you want to buy it? That's a totally different story. So now, it's hard to know which question to ask. I realized later on that perhaps the question shouldn't be, are you going to use this product? Or are you going to, to buy it? But the question should be, do you want to invest in my company, because that will probably tell you something about where the person is thinking of I think, well, this is going to be great success or not?
Patrick Kothe 34:04
Yeah, it's really difficult in that customer discovery phase, to get good quality, honest information, especially when you're taking it to your friends, your friends are generally not going to say, hey, water, I think you're nuts, you know?
Wouter van Furth, MD 34:20
Yeah, this is,
Patrick Kothe 34:21
this is not, this is not a good idea. They're gonna want to say hey, yeah, I think it's a great idea. You know, good luck with it. And then when it comes time to buy, that's a different story. And and that really, as you said, it's it's a very difficult thing to do even for experienced medical device people. You can ask all of the questions and ask them you know, do you want to invest even people I want to invest me may not tell you exactly how they're going to behave once the product is out there. It really is. You could do all of the customer discovery and try and get that real feedback from people, but you're never going to get it until you put a price on it. And you ask somebody to change their habit and adopt a new technology, it's a different animal.
Wouter van Furth, MD 35:10
Yeah. And I think change of behavior is very, very hard as Sergent, you're responsible for the good outcome. So to change something that I know I can do is difficult. And then we had a suit trade, it was a minor issue, you know, so so it was a nice to have, it wasn't a must have. That was also an important thing that if you want to start something new, it better be something like a totally new treatment, that that really changes how we're gonna treat patients. Well, for that I made, you know, for instance, in neurosurgery, coiling of aneurysms was a game changer. You know, before that we had no resin clips, we had to open the head and put the clip in. And all of a sudden color mannerisms became a possibility. And that that was fantastic. You know, and of course, you're willing to learn something because you have a new treatment modality that wouldn't exist, and you can treat patients safer than before. But that's a that's a must have. That's not an ICF.
Patrick Kothe 36:10
So where are you? You've been a listener of the podcast, and you reached out to me with a question, and it has it's right around this area. So what is the question that you want to ask? And we'll have an answer. We'll have several answers for you in the next episode, but what is the main issue that that you wanted to explore?
Wouter van Furth, MD 36:30
Yes, but my concern is about new technology and why certain technology is, is accepted and adopted widely, and why other technologies isn't and, and, of course, what we can do, if you're a medical device person to encourage this or to quickly on recognize where it's going to go. One experience I have is, is with spinal cord stimulation, which is not something I do personally. But I became interested in it. And I became aware that it's, it's very functional, it really works. It's expensive, but it really works. But it's last treatment modality is for patients, right, they've tried everything else, they have multiple spine surgeries, and they had spinal blocks and had this and that. And then spinal cord stimulation comes in as an option. So I have the impression is underutilized, even as a neurosurgeon, although I think it should be more often used. We don't use it, and I'm reluctant to set my patients there. And I wondered, again, why is this? You know what, why, although I think it will be more used? Are we not doing that? And what are the limits? For a technology like this, that clearly has its benefits, to be wise that more widespread, we accepted?
Patrick Kothe 37:44
As I'm listening to you, I'm thinking about two things. One is from a company standpoint, everyone thinks that their product is better, and it should have higher sales. And then there's another group of technologies where the clinical evidence is known. It is it's better than another way of practicing medicine. So you could have one technique that is demonstrated that it's better than another technique, but still, it is not adopted. So I think that you get to two things that are very similar, but a little bit different. And I want to kind of ask you that from a clinician standpoint, to talk Tell me about habits, and and why the habit is so ingrained in you and why it's so difficult to change.
Wouter van Furth, MD 38:36
Yes, great question. I think habits are always difficult to change. I mean, have you stopped smoking ever in your life? Or be on a diet? It's, it's hard?
Patrick Kothe 38:45
Are you looking at me right now talking about it.
Wouter van Furth, MD 38:50
It's a habit is is something that you built, and you get confidence in right? The way a surgeon is trained, is is very old fashioned, right? We learn from our masters and and they give you an example. And they learn from their masters. And this has been going on for I don't know, under 20 years or so neurosurgery isn't that old. So it's probably 100 years. Some of these things are just how we do things. Is there a good evidence for it? No. But he will tell you a case all I wanted this and it didn't go right. And so that kind of changed the way he's doing it. And of course, when you're in training you you adopt that. And then you have different people you've learned from so you make your own eclectic mix of how you do things a little bit from this a little bit from that, and this works for you. little of that is ever been scientifically proven, you know, and it's never going to be scientifically proven. It's, it's what we call in Dutch and unbuffed. It's something you deal with your hands, right? It's like the barber shop in the old times. It's something that you've learned how to do it, but there's a little true evidence for it. Then changing that. You all of a sudden You need really convincing evidence could be scientific data that shows you Okay, what I started doing this, it's actually better than that. But there's very little proven of what we do and very little research in, in medical practice, you know, if you particularly search, why would say, I have to think very hard about why I've changed something based on just a paper, you know, like somebody published something, I said, Okay, this, I'm gonna adopt this, this new way of doing things.
Patrick Kothe 40:32
What is your hesitancy to adopt it based on their paper? What what is what is holding you back from doing that?
Wouter van Furth, MD 40:40
Probably the patient mix, what did they do in their patient selection to have a patient mix that their procedure in this patient makes? Has this outcome? My patient makes maybe a little bit different? And is it different in an important way or not? I don't know. But will it work as well in my patient group? And do I have to kind of find out myself again, and and repeat their study or find out that I changed my my practice? And then I have more complications? Which is something you don't want to do? Right? So
Patrick Kothe 41:14
is that is that the big fear water? Is it the big fear that your that your results are going to be worse? Yep. With a new technique? It's the unknown.
Wouter van Furth, MD 41:25
Yeah, it sounds certainty. Yeah. I don't know if it's something simple, let's say, giving an antibiotic at the beginning of surgery. And there was a lot of research about that years and years ago. Clearly, that was shown beneficial, we're all adopting that, right. And if somebody would find something brilliant to reduce surgical infections, I don't know, some magical substance that you used to do surgery that will probably be widely accepted. But a lot of those other things are marginal, you know, and then it's going okay. Is this truly better? And and, and is that is that true for my patients as well, a patient selection, there's so many variables that are important in the outcome. So patient mix is hard to measure, and is never truly documented, rightly, in those papers,
Patrick Kothe 42:15
only asked about different categories of change. So one category change could be could be, you've got a needle driver, and somebody comes in with a better needle driver, or what they consider to be a better better needle driver. The risk I would assume would be minimal in that, so so replacement of one to the other with some features and benefits to it, maybe a lower risk that you would be willing to accept, but a change in technique, maybe a much higher risk. Yep. So as you said, with the spinal cord stimulator, it's a newer therapy to you, or it's a different therapy to you, it may have a higher risk associated with changing.
Wouter van Furth, MD 43:02
So with spinal cord injury, I'm not even thinking about doing it myself. It's I was just wondering about why are we not using it more in my group of neurosurgeons, we have a group of 20 neurosurgeons in three major hospitals together. And we're using it a little bit, but not a lot. And we still talk about it as almost as it's a failure that we have to do that. I was more going, you know, what, why is that because it seems like great, great device, and great results, but we're very uneducated about it, we know very little and so that was that was the example. I mean, the other example, for instance, is neuromodulation. for Parkinson's disease, it's it's there is very, very efficient, but it's also a last resort, and the numbers are relatively small. While it works fantastic. those technologies and and surgical techniques are there, they're used, but they don't. For one reason or the other. They're they're not as widely accepted as I would think. I myself, of course made a change from for instance, for certain schools meningiomas, I would always do an open surgery, and then I changed to endoscopy. And that was a major change, you know, not talking to you if thinking about Okay, why was I willing to do that? I thought it was better. There was some publications showing that it was better for visual outcomes at the cost of CSF leaks, which are solvable, we were learning about endoscopy and endoscopic surgery. So that was of an interest to us to see if if we could have the same skill set and do these procedures with the hope that it would benefit our patients. But of course, if you're going to do it the first time, you're not completely certain. When I did my first meningioma that way. I was very well trained. And I went to one particular five day course for the second time to make sure that I knew exactly what was going to happen and and I spoke with the experts at the place. They said, Oh, you're ready, you can do this, you know, you're okay. So I told my patient, I said, you know, you're the first one I want to do this with, but I think, you know, I'm sure I won't harm you. But if it will be significantly better than an open procedure, I'm not totally sure. And this particular patient, it was a lady and she said, Well, I prefer not to have a scar on my head. So why don't you do it? And so that's how we kind of made the agreement. And then once I did this first one, this was on a Monday. And there was a big case scheduled for Thursday for a colleague of mine, and he said, You know what? This went really well. Would you mind doing this one as well. So on Thursday, we did the second one. So once you reach that, you know, you, you have this change in behavior, and you notice it's going well, we are safe at it, we can do well, then doing the second one and following up on that is much easier. But that first step that took years.
Patrick Kothe 45:52
So water, that was 18 years ago, when when you were doing this, we're all getting a little bit older. So so 18 years later, you've got 18 years of habit that's been established right now. So if somebody comes to you today and says, Yeah, you've been doing an endoscopy for for 18 years, now I've got this new technique. What do you think your reaction would be?
Wouter van Furth, MD 46:20
I'm not, I'm not a pioneer. So I probably will wait it out and see how it goes. And and I'm probably an early adopter. I'm not a pioneer, certainly enough for somebody else's to do. If it's my own idea that's different. I like innovation, I think innovation is essential for us to make healthcare better and more affordable. So we should certainly give it a try. I've tried some new technologies. I've tried a new visualization technique, which is called an excellent scope. So it's, it's in between the microscope and and the scopes all in that sense, I was willing to give it a try very early on, I was probably the second person in Europe doing that. And then I've thought it was okay. But I wasn't thrilled by it. So we didn't pursue it.
Patrick Kothe 47:05
Yeah, much of this is cost benefit, isn't it? And it's what is the cost associated with a change? And what's the benefit associated with the change, and it has to be substantial on the benefit side, in order for you to take the risk, or a potential cost of the results of a change. So I think that that's, that's one of the main things. So we're going to get into this in the next episode with another guest. That's we're going to really dig into a lot of the different reasons why one technology would be embraced and another not be embraced. So I just want to say thank you very much for teeing this subject up because it is a critical subject no matter which technology or which product you're bringing into a clinician, the clinician makes a decision, am I going to adopt or not adopt? And what are all the reasons why it isn't? is or isn't isn't adapted. So thanks for teeing that up for us.
Wouter van Furth, MD 48:03
Sure. Well, thank you for addressing that, because I'm really interested. And I'll be a good listener to your podcast, you know, I'll follow you.
Patrick Kothe 48:11
Great. So water. Thanks for spending this time with us. Is there anything that you'd like to leave with our listeners who are working to bring different technologies and different devices into the marketplace?
Wouter van Furth, MD 48:28
Pat, thank you for that question. And yes, I like this opportunity, I think I have, I have two two things I would like to address to the to the listeners of this podcast. First of all, of course, my personal need, which is I do endoscopy for skull base surgery, and we need new devices. So if there's anybody there was a brilliant idea and is willing to put in some efforts, please do because, you know, if we can see around the corner, but we cannot do operations around the corner, and it's very frustrating to be able to see tumor, but not be able to get it out. So we leave remnants in places where we shouldn't I think the visualization techniques have developed tremendously and that's very important. But now we need to get access so we need smart devices that that have abilities to go around corners and and do tiny things from a distance and there's they're truly not there. It's a it's amazing and in the last 18 years, it hasn't evolved and and a very important one is for instance, bipolar forceps or some bipolar forceps is for and also be that are okay, but there isn't a beautiful one there isn't one that you go like this can really do what I want wanted to do. So I don't know if the market is too small or not. But it's it's there's clearly a need. The other one is perhaps more important. As a surgeon Of course, I've tested out new devices and new situations. And I've noticed that even though the device may look very similar to what you've used To Small changes can affect behavior and can affect the way the device works. And unwillingly, you sometimes put your patient at risk. And I believe that people in medical device world have a responsibility of being aware of that, and making sure that the person that's going to try this device out, is either properly trained, or is using it in a way that it cannot harm the patient. And this works, basically, for everything. So even, let's say a simple device, like a neuro navigation device, which is something we use daily and we know intimately, you get a software update, at least in the Netherlands, there's no mandatory training or certification that you now with the new software have to do this or that. They just update the system The next day, you and your ego like, Huh, I'm not totally sure why it's not doing what it's supposed to do. And even though the device looks very similar, it's not giving me the accuracy that I want, which may be important for that particular case. And then you go off, is it okay to accept this less accurate system, although I have an important case, are you going to cancel the case, this is frustrating. The other thing is, for instance, with drill bits, I've had experiences that you have a novel drill bit that that is specifically good for, for a procedure, you're like, Okay, I'm gonna test it out. But I tested it out in a real patient, and it worked well. But at some point, I put the patient a little bit at risk, which I shouldn't have done. So everything went fine patient had no problems. But in hindsight, it would have been much better if if I would have said I'm interested in his new drill bit, I'm going to test it out later on in a safe setting somewhere outside the EU or, or India or with I don't know, some piece of plastic or something, and not in a real surgery. And I think as surgeon, of course, I'm responsible, I'm not blaming anybody, don't get me wrong, but I think as as a device person, you should be aware of that, in new situations, searches, may have put their patient a little bit at risk using devices that they're not used to. I really hope you take it to heart and and I don't want to get you know that you need certification or something. But I do understand the reason behind that. I spoken with many surgeons about these topics. And a lot of surgeons recognize this that. Also, if you're outside your own comfort zone in your fence as you do in surgery, in another country, you get devices that you think, okay, I've never used this, but let me give it a try. It's a bit more risky than if you are in your own or with your own kind of things of yours.
Patrick Kothe 52:42
So many interesting things from that conversation. A few of my takeaways. First, it is a great big world out there. We often think about things from our own country's perspective. But we have to realize that there's a lot of countries out there, and each one of them has its own healthcare system on physician drivers own nuances. So the world is not monolithic. And every market, you're going to have different things like we discussed with water, it's physician motivation, based on what the system is, what their purchasing situation looks like, even have patient flow issues where some countries have waiting lists. And some people have fee for service models where people are rewarded for moving patients through the system faster. Often we talk about markets as if they're one as if Europe is all one market. And there's drivers that are the same for Europe, we have to recognize that France is different than Germany is different than the UK is different than another lens. They're all different. And we have to understand that there are nuances within those different marketplaces, and that our products are going to be adopted differently depending on where you are. The second we discuss motivation for change. And this is where I really thought that it was interesting. And this is where I could hear Wilder thinking about what his motivations are and doing some introspection there. So he really understands the type of buyer he has. He's not the pioneer. He's the early adopter. So he understands that about himself. And it sounds like it was a conscious choice. To do that. He discussed how a simple change is easier to adopt than a complex change. But there's got to be a benefit that's large enough to put up with the potential cost in making the change. And the other thing he discussed his personal results. It's not just what you take from what other people are doing, but what are your personal results and how are your personal results potentially impacted by any change that you're To make, and then within that personal results category, I thought it was really interesting and subtle when he talked about how he reviews clinical papers, and are the results being reported within his patient population. As we're discussing papers with clinicians, it's really something I think we need to look closer at is what is the patient population and doesn't match the patient population of the clinician that you're speaking to subtle, but can be a really interesting thing to explore with our customers. Finally, the last thing is his question. His question your Why are some technologies adopted while others are not? And that's true for all of us? We all have that question. Whether it's, you know, we're introducing a new product and we say, geez, why isn't the market accepting this the way I think that it should, or you can look at it from a broad technology perspective, and say there's this category of products that aren't being utilized in a way that they probably should, based on the clinical data that's out there. So we're going to dig into that pretty deeply in the next episode with with a guest that I'm going to have that's also launched quite a few products in his career. So I think that that's really going to be a nice way to wrap up this question that water raised today. Thank you for listening. Make sure you get episodes downloaded to your device automatically by liking or subscribing to the mastering medical device podcast on Apple podcast, Spotify, or wherever you get your podcasts. Also, please spread the word and tell a friend or two to listen to the mastering medical device podcast. As interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
