Clean Kill

Score another one for laparoscopic gallbladder surgery.

If only the world had listened when it had the chance.

But then, the same could be said of many things.

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.

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