U.S. healthcare is awash in medical technology, and recently, in an editorial published on Bloomberg.com, one surgeon suggested that we may be drowning. For as Dr. Craig D. Turner, a urologist in Portland, Oregon points out “what is different with the new wave of technological marvels is that many are heavily driven by marketing; here he links to an ad by GE Health touting wide-bore MRIs “Simply Powerful, Powerfully Simple.”
New technology always poses risks, he points out, because it “requires that physicians master arduous new skills” which means that while doctors climb a steep learning curve, some patients may be hurt. Someone has to be one of the first hundred patients a doctor learns on. Meanwhile, often, the new, new thing “lacks clear benefits compared with established and less-costly technology.”
Innovation is proceeding at a pace that helps drive waste: “One health-care administrator told me the basement of the hospital is full of million-dollar machines collecting dust — not because they didn’t work or because they were ineffective, but because they have been displaced by newer technology.”
“Now 10 years into surgical practice, I have learned some hard lessons related to new technologies,” Turner admits. “Patients often are put at greater risk as we physicians scale the learning curve. . . More things can go wrong.”
Here he turns to surgical robots: “They are costly and require significant re-training for surgeons.” But “consumers hungrily seek out surgeons versed in” the use of robots. . . . Hospitals do nothing to discourage this and engage in the kind of tawdry marketing more familiar on late-night infomercials by using patient testimonials. ‘I cannot believe how quickly I recovered,’ a vigorous-looking patient is quoted as saying.
“As a surgeon I have to ask: Where is the data? Was the recovery any quicker than in a procedure done without a robot? Would another surgical approach have served the patient as well? And cost a lot less?”
He then goes on to recount what can best be described as a love/hate relationship with the robot he uses in surgery. “In the first decade of practice I was enthralled with the amazing new technology,” Turner confesses. Now he is not so sure.
When A Robot Takes Over in the OR
Since 2004, Turner reports that he has been using a robot known as da Vinci, developed with funding from the U.S. Army “with the main goal of allowing the surgeon to operate through telepresence at a safe distance from a wounded soldier on the battle field.”
In that context, robotic surgery makes great sense. We cannot afford to lose army surgeons by sending them into the center of the battlefield.
But in the civilian world, the benefits fade: “In a hospital setting, the surgeon sits in the corner of the room at a master console looking into a 3-D virtual view of the surgical field. Hand movements of the surgeon are translated to the robotic arms at the bedside a few feet away. This disconnect of surgeon from patient comes with a $2 million price tag (for the robot) and costs $2,000 to $3,000 each time the device is used.”
I have to wonder about the risks of “disconnecting the surgeon from the patient” in a situation where the distance isn’t necessary. There is some evidence to suggest that men who undergo robotic surgery stand a greater chance of winding up incontinent, though it is not conclusive.
As for benefits, “I try to tell my patients there is no conclusive data aside from reduced blood loss to show the da Vinci is significantly better than open surgery,” Turner confides. “There has even been some data to suggest cancer control can be compromised with robotic surgery.”
The fact is that we just don’t know. As the New England Journal of Medicine reported in August, “To date, there have been no large-scale randomized trials of robot-assisted surgery, and the limited observational evidence fails to show that the long-term outcomes of robot-assisted surgery are superior to those of conventional procedures.”
This is in large part because patients have refused to take part in such trials: “When I first started doing robotics, I wanted to do a randomized clinical trial comparing [conventional] surgery to robotic,” explains Dr. Mani Menon, a professor at New York University and chair of the urology department at Henry Ford Hospital in Detroit, who pioneered the use of the robot for prostate surgery.
But as he informally surveyed patients, he discovered that “although the patients all agreed that a randomized clinical trial would ultimately end up giving the truth, none would want to participate themselves. Patients don’t want to be randomized because they know what they want. Some preferred open surgery because they knew I’d already done 1,200 cases. Others preferred the robot . . .”
Thus, in lieu of medical evidence, we have marketing, and that marketing has been extremely effective. In 2009, 73,000 American men — 86 percent of the 85,000 who had prostate cancer surgery—had robot-assisted operations, according to the robot’s maker, Intuitive Surgical—up from “fewer than 5,000” in 2002.
A great many patients love the idea of “Star Wars” technology: “When I tell prospective patients and their families that I plan to use a robot, more often than not they grow wide-eyed and awe-struck,” says Turner. “Lost in the discussion is that I have actually become dependent on the da Vinci.”
The robot that he once embraced with such enthusiasm has robbed him: “My skills with standard laparoscopy have suffered to the point that I am now reliant on the robot to assist me in performing some of the finer movements of the surgery. Rather than being viewed as incompetent, though, I am seen as the priest who, imbued with the power of robot, will deliver the patient from the shadow of death.”
“Innovation should make things more cost-effective and safer while ensuring better results,” Turner concludes. “Therefore we must use only the most appropriate innovative technology and use it wisely. Moving into my second decade I hope to temper some of my enthusiasm with a bit of good old-fashioned fiscal responsibility. If the new technology isn’t lifting the quality of care, or lowering costs, why are we using it? Perhaps one patient in a thousand would benefit. But four patients might well be better off if they opted for a less aggressive, low-tech procedure.”