Self-driving Cars and Surgery: Up with Robots, Down with Skills

Imagine that you have just purchased the latest self-driving car and you are on your way to work. The car is in control because the route is familiar and the car has all the modern sensing and decision-making functions. You assure yourself that you can take control of it at any time. But if there is a sudden dangerous situation—someone darts into the road or another vehicle is moving erratically—will you do so? I venture that the answer is yes if you are an experienced driver of old-fashioned cars that need to be driven—your instinct will be to rely on your own skills to avert problems. If you learned to drive after the self-driving technology was the standard? I’m guessing the answer might be no. And the answer could be very consequential.

Research by Matthew Beane published in Administrative Science Quarterly explores a situation with similarities to this one. He examined what’s happening in operating rooms around the world, where robots are increasingly used to perform surgeries. At least for the moment, the most effective robots do not make their own decisions, but they can be controlled quite effectively by a single surgeon at the control panel. That single surgeon often no longer needs a team performing different surgical tasks for the operation to go smoothly. And that surgeon is not likely to give up the controls during a challenging operation to a medical intern who needs to learn how to perform the surgery.

If you’re the intern, that leaves you in a position of scrambling for any opportunity you can get to practice with the new technology so you can gain the necessary skills to guide the robots. At the same time, you aren’t (as often, at least) part of a surgical team performing traditional surgeries, so you aren’t building the skills that are essential backups if something goes awry during the robotic surgeries you’re observing.

Surgeons don’t live forever. What happens when they are replaced by the interns who are currently receiving less hands-on training than they had? I guess we’re all going to find out.

We immediately understand that less training of surgical interns is a very bad idea, but that does not solve the dilemma. Surgeries using robots are performed best by the most experienced surgeons with minimal help, so actively involving residents adds time and risk. The residents can do little more than observe the surgeon controlling the robot. The onus was on the residents Beane studied to learn the skills with minimal costs to the attending physician in charge. And some of them did, showing significant ingenuity in the process.

Because the robots were only supposed to be used by the most qualified surgeons, only two approaches to learn were open to the residents. They could learn when the surgeon was not there, or they could learn as a favor from the surgeon. Learning when the surgeon was away could be done before they even became residents at the hospital, if they were lucky enough to be in a place with the right equipment and surgeons who allowed them to practice. It could also be done by watching recordings of earlier surgeries, though this type of training only showed what the robot did, not how to use the actual controls.

The other option is to learn from the surgeon during an actual operation. Usually that means getting control of the robot during the less critical part of the operation, and being watched over by the surgeon at every step. This approach is fast and accurate, but it also means that any mistake becomes very visible, and usually leads to the surgeon taking over the controls right away. It is the best way of learning, but also the scariest one. The risk was real because residents would be compared based on very few operations, and surgeons would prefer to continue working more with those who had done best – whether it was because of skill or because of luck.

The difficulty of learning when robotic equipment takes over a production process but still needs human control is not just in hospitals. The self-driving car is an example, and there are many examples of more subtle processes. The software that recommends whether an applicant can get a mortgage or not, and at what interest rate, is an invisible robot that can be controlled by the bank employee. But as the software gets smarter and the employees get less training, they have less foundation for checking its work, or even to be employed at all. Robots are smart, but organizations need to use them smartly.

that less training of surgical interns is a very bad idea, but that does not solve the dilemma. Surgeries using robots are performed best by the most experienced surgeons with minimal help, so actively involving residents adds time and risk. The residents can do little more than observe the surgeon controlling the robot. The onus was on the residents Beane studied to learn the skills with minimal costs to the attending physician in charge. And some of them did, showing significant ingenuity in the process.

Beane, Matthew. 2019. Shadow Learning: Building Robotic Surgical Skill When Approved Means Fail. Administrative Science Quarterly, 64: 87–123.

There is also a TED talk on this research. 

How Does Knowledge Speak to Power? Friendship First

Here are two facts that should open your eyes. First, more than a decade of Iraq and Afghanistan warfare has increased the mental health diagnoses in the U.S. military by 65 percent. Second, a mental health provider will recommend treatment of an unstable soldier, but the military commander can still send the soldier out on a mission – fully equipped with service rifle, grenades, and sidearm. This sounds like an extreme case, but it is actually an example of a common problem. Organizations use experts for many purposes, including those who control risks to human life, equipment, or finances, but the experts are often just advisors. The actual authority rests with the line manager in charge of operations.

The difficult relation between the non-authority expert and the authority non-expert is important to understand because the whole point of experts is to take advantage of their expertise when needed. Now we know more, thanks to an article by Julia DiBenigno in Administrative Science Quarterly. She investigated the example I just gave: U.S. Army mental health providers and their relationship with line managers (commanders) who decide how soldiers are used or treated. This is a follow-up of an earlier article byDiBenigno showing that organizational procedures can be used to help create a more successful relationship. But even in organizations that are set up correctly, individual experts can still fail to reach the powerful line command.

The main difference between success and failure was timing and speed. The mental health providers had a wide range of tactics to gain access to the commanders and subsequently gain their trust. What tactics they used depended on their resources. Because the army values military experience, anyone with military service or endorsement could use that to be recognized as an insider. Because the army values manhood, participating in rigorous training signaled commitment. Because the army values rank and protocol, learning and strictly following these helped communications. Doing each of these things quickly was essential because any specialist will sometimes make recommendations contrary to a commander’s wishes, and it is essential to build rapport before the first conflict happens.

A worrying implication of this research is that so much depends on the personal characteristics and initiative of each expert. Two-thirds of the provider–commander connections were good enough that the commander often followed the provider’s recommendations. What about the soldiers under the command of the other one-third of the commanders?  One-fifth of the providers were currently serving in the military, giving them a great advantage in gaining commander trust. What about the other four-fifths of the providers? Half the providers were female, in a context where gender is very meaningful. They would start out at the bottom rung of the trust hierarchy but could climb by, for example, participating in training. The men started out higher on the trust hierarchy but might fall quickly if they didn’t prove their manhood.

All these findings suggest that the expert’s path to influence is a complicated one in organizations. My intuition is that it is probably worse in many other organizations than the army, for two reasons. First, the army is a pretty nonpolitical organization if we go far enough down the ranks – its culture of valuing “straight shooter” communication rather than intrigue reduces intra-organizational politics. Second, an army at war has an external enemy and an understanding that all insiders – even mental health care providers – are on the same team.

The best advice to line managers from this research is to pay very careful attention to the experts, because many of them will not know how to gain trust and communicate their concerns. They need managerial attention and help, and you need their expertise.

DiBenigno, J. 2019. Rapid Relationality: How Peripheral Experts Build a Foundation for Influence with Line Managers. Administrative Science Quarterly, forthcoming.

Competitive Slander: Using the Media to Wage Market Battles

We often see signs of organizational competition in the market turning into battles fought on multiple fronts. Apple and Samsung have good-looking telephones that compete vigorously in the market, and their lengthy Patent War is famous. Ride-sharing firms Lyft and Uber compete in the market but have also accused each other of covertly placing fake orders and then canceling them. They also fought in the media when Uber used taxi workers’ protest against the U.S. immigration ban as a business opportunity: Lyft struck back with a strong stance against the morality of Uber’s efforts and made a donation to the ACLU, which accelerated the trend of #DeleteUber across social media.

Just how far will organizations go in such battles? A forthcoming article by Benjamin M. Cole and David Chandler in Administrative Science Quarterly looks at the famous War of the Currents between Edison and Westinghouse and finds ample evidence of how such battles can escalate. The War of the Currents started when Westinghouse realized that the Edison direct current (DC) electrical system could not be used for long-range transmission of power. He obtained the necessary patents for alternative current (AC), which transmits much more efficiently, and his company was soon a major competitor of the Edison companies. The market competition expanded into a full-blown rivalry when Edison started using competitive slander to turn media and consumers against AC and Westinghouse.

Edison’s recipe was simple: Make the newspapers publish stories about experiments showing that AC easily killed dogs and other animals, so that people would associate AC with danger—unlike the safer DC. A simple strategy, but also a grotesque one. To make it work, he needed to conceal his association with the experiments, having an electrical engineer act as the front man, and also make them seem legitimate by conducting them in famous institutions’ facilities. As a final step, his company made direct contacts with politicians who could influence the marketplace.

The campaign worked because it was well orchestrated and because Westinghouse initially thought there was no need to strike back. This left Westinghouse exposed, and when his company did respond, it chose an ineffective approach—directly countering the Edison attacks through attempts to discredit the message and expose Edison’s methods as sensationalist and immoral. This was ineffective because Edison had chosen a vulnerable point to attack: although killing dogs is immoral, it correctly illustrated that AC is more dangerous than DC at comparable voltages.

I suppose we could have all ended up with expensive DC as a result of this rivalry. But in the end, Westinghouse won by returning to the foundation of the AC advantage: it is a superior system for distributing electrical power over long distances. He won the bid to illuminate the city of Chicago as part of the World’s Columbian Exposition. He sank considerable resources into the contract, making it a financial loss but a spectacular success as a PR event for AC and for Westinghouse technology. Soon after, AC dominated and even Edison started marketing AC systems.

The War of the Currents has many lessons for current organizations, and I want to highlight one disturbing and one promising lesson. The disturbing lesson is the effectiveness of attacking: when the attacker picks the target well and is willing to go far, the rival is very likely to get hurt. The promising lesson is the effectiveness of sticking to basics: when the rival emphasizes its own strength rather than countering the attack directly, its chances of recovering are best.

Cole, B. M., and D. Chandler. 2019.

"A Model of Competitive Impression Management: Edison versus Westinghouse in the War of theCurrents." Administrative Science Quarterly, forthcoming.