Wednesday, December 17, 2008

Ay Yi, Robot

I add to my recent posts on medical cost issues: In our local newspaper (I still have a fondness for ink) there recently appeared a news article profusely exhuberating the arrival in town of a 1.5 million-dollar surgical robotics device. Not a wait-a-minute word among them. The mentioned surgeon is sure to have an instant waiting list; the hospital, another feather in its heady hat.

Here's an opinion piece I submitted to the paper. I'm told it'll be published soon:

In response to a recent article in The Herald, and recognizing the risk that my duddy might be seen as fuddied, I’d like to comment on the arrival of the 1.5 million-dollar robotic surgical device in Everett. Allow me a few drops of cool – if not entirely cold – water.

Years ago, with the arrival of laparoscopic surgery (done through small holes with cameras and special tools), I learned how to remove gallbladders in that new and highly important way. At the time, lasers were used for much of the internal cutting; in fact, the word “laser” was part of the name of the operation: Laser Laparoscopic Cholecystectomy. Exploring the technique in learning labs, we used both laser and traditional electro-surgical machines. I found no advantage for the former, and since lasers cost several tens of thousands of dollars, I asked the instructor (an employee of the laser company) why we should buy one. “Because,” he said with no evident irony, “it’s what patients want. If they hear you’re doing the operation without a laser, they’ll go somewhere else.”

Gathering dust in hallways of hospitals all over the country are lasers bought for the purpose. Virtually nowhere are lasers used in laparoscopic gallbladder surgery any more: they were indeed found to confer no special benefit. Which calls to mind a quote from the recent story: “
A lot of patients have been reading about it as the newest and best thing and asking for it…

Don’t get me wrong. Robotic assist devices have an important role in the future of surgery. In fact, perhaps the greatest potential was not even mentioned in the article: because the robot is in the operating room and the operator is at a separate console, the surgeon doing the work can be, theoretically, anywhere in the world. (Anywhere with a highly reliable broadband connection, that is.) Herr Doktor Emmenthaler, while sitting in his office in Geneva, could remove your tricky brain tumor right here in Everett! In fact, similar things have already been done. Originally, surgical robotics were developed with battlefield surgery in mind. We surgeons could sit safely behind the lines while the poor medics hooked up the machines as the bullets flew.

So what’s my point? Just this: to date, there really isn’t much evidence that outcomes of robotic surgery are significantly better than those of more standard approaches. In fact, some studies have shown no difference other than higher cost with robotics. Specifically, the advantages mentioned in the article – small incisions, magnified views, short stays – are already the norm with, for lack of a cooler term, flesh and blood laparoscopy. So far, much of the excitement is because surgeons (speaking not only for myself!) love new toys and fresh challenges, and because, as the article confirms, hype directed at patients has rarely fallen on deaf ears.

Times are tough, and getting tougher. Ultimately, fixing our struggling economy will require fixing our failing health care system as well. At the heart of it is cost. So far, most of the effort at cost containment has been in cutting reimbursement to providers. Ain’t no more blood in that particular turnip. At some point, we’ll need to take a really hard look at the actual delivery of care. What works, what doesn’t. Which ways to solve a particular problem make the greatest overall economic sense. Most of the cost of an operation is generated in the operating room; an hour there can cost more than a day recovering in the hospital. So it’s not just about sex appeal. It’s about hard numbers, carefully generated. When we get around to that, not everyone will like it.

Funny story: in my career I developed a way of removing gallbladders through a single very small incision, without the tools and troubles of laparoscopy. Like the laparoscopic operation, it was done mostly as an outpatient, with as rapid recovery and return to work, and (trust me on this) fewer complications. Because of the much simpler equipment and shorter operative time, someone saved well over a thousand bucks every time I did it that way. But it never caught on among my peers. The secret will die with me. There’s a lesson in there, somewhere.

The hospital folk might not like it, but it won't be the first time I wrote something that caused their ire. It happens to be an excellent hospital, consistently highly ranked nationally for its heart services, and statewide for pretty much everything else. Given the current realities, they must do what they must do to attract patients, particularly the surgical kind, from whom they have a chance to make a buck or two. If this tack is cynical, it doesn't follow that it's unnecessary: in this ass-backwards era of ineffective cost-management, it's reality. The purchase and publicizing of a million-and-a-half dollar machine of dubious value is seen as appropriate. And until we get around to the hard stuff, maybe it is.



  1. Ahh Sid, so many easy targets to chose from...BTW, whats this "Newspaper" thing??? Don't have em in Georgia...Yeah, that Laparoscopic thing never caught on...Real Reason the Robots are gonna win, unlike in Terminator 2, even if they aren't quite as smooth with a pair of Mayos, they won't sling em' across the OR, or show up with Beer on their Robot Breath, or play Polish Polkas for 6 straight hours, longer than allowed even at Gitmo...Had LASIK a few years ago, and THANK GOD it was a Robot, damn Ophthalmologist's hands were shakin worse than Ted Kennedy's after 4 hours of abstinence...guess thats what I get for goin for the $49.99 special...Thats whats nice about Anesthesia, there's some jobs even Robots won't stoop to doin....Last Human to leave the OR, turn out the lights, Robots don't need em...

  2. Actually, Frankie, you are finally wrong about something*: the surgical robots need a human. But anesthesia? Haven't you heard about this?

    *unless you count everything.

  3. I'm genuinely sad that no├Âne'll ever listen to you. This is hardly the platform that'll get you elected to public office. And even if it were, you'd not be able to bend any arms enough to get people to grow the frag up.

  4. Sid, it would be fascinating to know the 'actual' cost of said Robot, wouldn't it?

    There are the obvious costs: research and development, manufacturing, etc.

    Then add on the profit to the company, and the huge commissions the sales reps make.

    I'm sure that finding the actual numbers, broken down, would be as elusive as finding the Holy Grail.

    Which, in thinking, perhaps that's part of the reason the company dame up with the name 'Da Vinci'. =)

    And how will...or will, insurance companies cover the addition costs of robotic systems, or will they be considered 'experimental'?

    And what about Surgeon compensation? Any difference there?

    It's been a while, but I recall some of the Cardiac Surgeons I worked with being upset that Medicare had set a dollar limit for a CABG reimbursement. It didn't matter if it was a 60 minute off pump variety or a 12 hour nightmare case, the compensation was the same ($1500 at the time).

    Technology is great. I'm a fan, but when medical care and Big Pharma are being so heavily marketed to consumers, cost containment will continue to be a huge problem.

    Speaking of marketing; the last hospital I worked for? The CEO's education and work experience was all in Public Relations.


  5. The robot, made by Intuitive Surgical in Silicon Valley, has a steep learning curve. All equipment used with it is disposable, hugely expensive but can be BILLED. Prostatic removal by this method has been around for 3+ years, and our experience is that recurrences of cancer are actually more common. Hospitals are fighting tooth and nail, huge billboards advertise their wares along freeways, and "I'm having my operation by robotic technique" not the "old-fashioned way" has a ring to it that patients cannot resist. They are probably here to stay, but not much better than the tail-fins made the 1956 Cadillac. Be sure not to be in the first 200 your surgeon has "tried".

  6. Kristi: you raise another important issue, about which I wrote on my other blog, I think: it's true of all operations. You get X amount for a colon, Y amount for a gastrectomy, no matter the "degree of difficulty." And, more frustrating, no matter how well it's done; ie, if by operating more efficiently and having quicker recoveries, fewer complications, your cost per case is less than another surgeon's, you still get X, or Y, and so does he or she.

  7. Dr Baldwin: you, too, make an excellent point. The tail fins of the 1949 Cadillac, of which I was once a proud owner, were perfect, and needed no improvement.

  8. A little OT, but thought you'd enjoy - Those beloved drosophila are being helpful again.

    I also discovered that SUSA is developing a 20 item interactive website for individual, community, state, regional and national health indicators with advocacy tools. All based on IOM measures and reliable and valid tools and measures.

    I've been tooling around the site, and I don't see where they are going to post indicators for healthcare resources, but this certainly looks intriguing and will be fun to play with.

    Selection Criteria and Framework

    Ultimately, the 20 IOM indicators will be part of a new Web site that provides other accessible measures – along with equally vetted data -- across a range of topics, including health. Key indicators for the economy, education, the environment and other national concerns will be delivered in a way that enables exploration and surfaces connections across categories

    The committee took this into account in developing its selection criteria. Its report emphasizes that one's physical environment, such as air and water quality and housing, and the social environment in which people live, work and play, are fundamental determinants of health. However, such measures were not included in its list health indicators because they are expected to be captured in the development of other issue areas for the upcoming State of the USA Web service. Those issue areas include the economy, education, the environment and several more.

    The committee's report also underscored the importance of identifying socioeconomic and race and ethnicity disparities across a variety of issue areas, calling them "crucial to a better understanding of the determinants of health and health outcomes."

    With criteria in place, the committee organized its selections in three categories – health outcomes, health-related behaviors and health systems. The resulting recommended health and health care indicators are:
    Health Outcomes

    * Life Expectancy at Birth:
    * Infant Mortality:
    * Life Expectancy at Age 65:
    * Injury–Related Mortality:
    * Self-Reported Health Status:
    * Unhealthy Days, Physical and Mental:
    * Chronic Disease Prevalence:
    * Serious Psychological Distress:

    Health-Related Behaviors

    * Smoking:
    * Physical Activity:
    * Excessive Drinking:
    * Nutrition:
    * Obesity:
    * Condom Use:

    Health Systems

    * Health Care Expenditures:
    * Insurance Coverage:
    * Unmet Medical, Dental, and Prescription Drug Needs:
    * Preventive Services:
    * Preventable Hospitalizations:
    * Childhood Immunization:

    Whenever hospitals purchase the bells and whistles such as the robot you're referencing, they most often concomitantly layoff, fire and contract professional nursing positions. Because this is usually hidden by slashing across nursing units and services, the public and indeed the hospital's board of directors and physician organization, aren't even aware for the most part.

    Since the absence of professional nursing is at the root of the vast majority of preventable medical errors, just thought you might be interested in how resource allocation works behind the scenes and angel screens.

  9. Let's see...same pay, no matter how well or how badly you perform. What does that remind me of? Oh yeah--a union job. Maybe the UAW should organize the surgeons--then we'd be bailing out another overpaid group.

  10. anonymous: I love you for your mind.

  11. I wonder how many surgery center owners will purchasing Da Vinci platforms? My guess is ZERO! Too expensive and would take forever to amortize the cost. Odd that the appeal seems to be "how do you do it, not how well do you do it. Yikes! Dr Baldwin reports increases in recurrence-how would that look on a bill board-

  12. Excellent letter, Sid.

    Will you let us know when and where it gets published? It's brilliant.


    Ellen Kimball in soggy Palm Desert, California
    (350 days of sunshine, but not yesterday OR today!)

  13. Thanks, Ellen. I'll try to remember to leave a link in this thread. Possibly Saturday.

    I-5 in Portland, as you probably know, has become an ice rink. Be glad you only have rain down there.

  14. Sid and Ellen,

    The weather's no better here in Arizona. Rain in the Valley for days and lots of snow in the high country.

    That's especially 'wonderful' as we're planning a driving trip back to Iowa for Christmas.

    That is, if we'll even be able to get out of Arizona.

  15. Addendum: Driving my kid to school today I passed this sign at a place of business: "Tuolumne Veterinary Hospital, small and large animals, exotics, emergency service, Specializing in Laser Surgery." See...even the animals are demanding new tricky stuff

  16. Dr. Baldwin:

    Good Lord! Laser surgery for pets?

    Thanks, but no thanks. I'm sure that's more along the marketing lines we've been discussing and directed toward the types that carry their Yorkie in a Prada bag.

    Now don't get me wrong, I'm a huge animal lover. Iowa farm girl born and raised. We currently have 5 Shar Peis, 3 of which are rescues. If my hubby would allow me to have more, damn right I would! (best breed ever!)

    But Veterinary care can really add up quickly and given the choice? I'd do for my pets just as I'd do for myself...follow the K.I.S.S Method.

    Keep it simple, Stupid.


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