Surgical Robots are Great, Unless You’re Not Trained to Use Them?

The idea of “surgical robots” is an interesting one. As a Lean guy, I'm naturally somewhat skeptical of technology – not to be a Luddite, but GM was the company that wanted the high-tech lights-out robotic factory (a vision that never came true) while Toyota invested in people and relatively low-tech processes and technologies to beat the snot out of GM in the market.

Paul Levy, CEO of BIDMC in Boston, wrote a blog post back in 2007 where he asked where the evidence was that surgical robots were better than regular surgery. He said, in part:

Notwithstanding the lack of evidence of enhanced clinical efficacy, I have been advised the following by one of our leading doctors:

Due to market forces beyond any of our control, the unfortunate reality is that without a DaVinci robot, BIDMC prostatectomy volume would likely plummet by 2010 and BIDMC would consequently quickly become a non-entity in regional prostate cancer care.

The WSJ had an article recently that raised the important issue of whether or not these surgical robots lead to better quality or not.

Levy decried the technological arms race (as quoted in this WSJ article) that pressured their hospital into having one of these robots. The article gives evidence that having the robot is a profitable business decision for some surgeons and some hospitals.   The WSJ article cited a relatively small New Hampshire hospital that had to have one:

Wentworth-Douglass Hospital, a small community hospital in this coastal New England town, used a college hockey game to showcase its new technological marvel: a $1.4 million surgical robot named after Leonardo da Vinci.

Ah, technology. Healthcare probably has more of a love affair with the latest and greatest technology than manufacturing industries do, generally speaking. I visited one hospital (to be unnamed) and they bragged about their da Vinci robot, showing me (through the window) the crowd that was gathered in the O.R. to see the second surgery of some type that was done in that state with the robot. All the while, their basic systems and processes were pretty broken. High tech + bad processes = blah.

You might ask, “So what could possibly be bad about this latest and greatest technology, Mark?” You love your iPhone, you blog, you embraced Twitter… I'm not against technology. I'm against bad process and bad results.

From the WSJ:

At Wentworth-Douglass, however, the robot has been used in several surgeries where injuries occurred. One patient operated on days after the hockey game was so badly injured that she required four more procedures to repair the damage. In earlier robotic surgeries, two patients suffered lacerated bladders.

There's no evidence to suggest the injuries at Wentworth-Douglass were caused by technical malfunctions. Surgeons who use the da Vinci regularly say the robot is technologically sound and an asset in the hands of well-trained doctors. But they caution that it requires considerable practice.

If you're a factory person, think about that latest and greatest robotic CNC machine. Would you let a barely-trained machinist use it? If you did, would you expect perfect results? The problems with the surgical robot sound like a process, training, and management problem, not a technology problem.

Again, from WSJ:

As a small regional hospital, Wentworth-Douglass has used the da Vinci about 300 times in four years. That's a fraction of the usage rate of some big medical centers and, some surgeons say, too little for the doctors at the hospital to master it.

Practice makes perfect (or closer to it). In books by Gawandeand others, there's a good case to be made that higher volume (more repetition) leads to better results in situations like hernia surgery and organ transplants. If you need a liver transplant, you don't want to be the only one that's done in that hospital in a given year. You want to be in a hospital that does LOTS of liver transplants.

Some in the medical community warn that the training / repetition issue is an important one:

Some of the hospital's surgeons opposed getting the robot because they felt Wentworth-Douglass didn't perform enough surgeries to overcome the machine's long learning curve, several current and former members of the medical staff say.

Some surgeons with extensive robotic experience say it takes at least 200 surgeries to become proficient at the da Vinci and reduce the risks of surgical complications. That's difficult for surgeons at smaller hospitals to achieve.

Jim Hu, a surgeon at Brigham and Women's Hospital in Boston who has done more than 1,000 surgeries with the robot, says it takes a urologist anywhere from 250 to 700 cases to master it. Dr. Hu considers the da Vinci a clear benefit for experienced surgeons, saying, “You can do a better job.” But he cautions it can do more harm than good when used without adequate training.

More harm than good without adequate training? Yikes? You mean surgeons and hospitals would move forward without proper training? Shocking to a Lean thinker, especially in a life and death industry.

So if you've bought this expensive robot that isn't being used enough to justify its expense, what would you expect to happen? If you're a cynic, you'd expect pressure surgeons to increase the utilization.

The hospital also began pressuring its surgeons to use it, the current and former members of the medical staff say. Dr. Lambert, who left to become an assistant professor of surgery at Upstate Medical University in Syracuse, N.Y., says the pressure contributed to his departure.

Again, yikes. That's a major “are you serious??” moment, eh?

Training?

Some current and former members of the medical staff say the training Wentworth-Douglass offered on the robot was insufficient. It included two days of operating on pig and human cadavers at a hospital in New Jersey.

Upon their return, the trainees started operating on live patients.

Again, from the article (keep in mind that some said you need 200 surgeries to be proficient):

At Wentworth-Douglass, surgeons begin doing da Vinci surgeries unsupervised after four cases.

Some surgeons realize that's not enough training and practice:

Dr. Hu of Brigham and Women's [in Boston], who did a one-year fellowship and assisted on 400 robot surgeries before he began operating solo, says that's much too soon. “None of us would go and get surgery if we knew the guy had done it just a couple times before,” he says.

Wentworth-Douglass's four urologists resisted using the robot without more training, people familiar with the matter say. Three of the four ended up leaving the hospital.

Again, I can't say anything but yikes.

So those who started using it anyway — they're doctors, what could go wrong?

Unlike the urologists, the hospital's gynecologists started using the robot. Several complications occurred. The bladders of two female patients were lacerated during routine gynecological surgeries performed with the robot, a person with direct knowledge of those cases says.

One of the patients had to be sent to the Lahey Clinic in Burlington, Mass., for another surgery to repair the damage, the person says. The patients survived. A spokesman for the Lahey Clinic declined to comment.

The hospital claims those injuries aren't specific to the robot, but I guess none of us can tell.

I posted a link to this on Twitter and got a response from a medical professional:

Brandi Bax (@brandibax) wrote:

5/5/10 4:30 PM
@markgraban I'm actually quite familiar with DaVinci. It grates on me that docs can be cut loose on this w/ minimal education. Irresponsible.

And she added:

5/6/10 9:27 AM
@markgraban …have productivity numbers they must meet and can't take time away for meaningful education on complex equipment.

Any time you have financial pressures on equipment and productivity targets to hit, bad things are likely to happen in quality. This is true in any setting and it seems worse in healthcare.

Are all surgical robots waste? Of course not. Am I glad we have the technology for when it's needed? Sure! But only with proper training and process. Anything else does seem irresponsible and we should demand better from the medical profession than to have poorly trained surgeons operating on people with the latest snazzy gadgets. What do you think?

I hope you have access to the WSJ article, it's a fascinating read. It drew 53 reader comments, which is relatively high for a non-political WSJ article. Reader comments on a news site (not this blog!!) are often a cesspool, so reader beware, I say.

One reader gave an example of more technology cost run amok:

My own dentist reported to me how he was solicited to buy a $20,000 laser scalpel. He told me that he could do the same job as the laser with a scalpel blade which costs under one dollar.

This might be one reason why healthcare costs skyrocket while quality is still relatively poor?

One other reader blamed the general public, not the docs:

This is the problem with the lay public. They don't know a thing about medicine and they are impressed by such non sequeters as a robot. If someone told me they were going to use a robot on me, and they didn't have 1000's of cases under their belts, I would run, not walk to the nearest exit.

Yes, we're generally wowed by technology, not training and process. It's like blaming the voters for the mess we have in Washington… shouldn't the surgeons and hospital administrators carry the burden, not the patients?

One commenter, claiming to be surgeon (we'll believe him, I guess) told this horror story:

I was in practice for 5 years and went back to do a ONE YEAR fellowship in robotic and laparoscopic surgery in the context of urologic oncology. First hand I have seen the difference between my results and another same age surgeon who went away for a weekend course. I have had no reoperations, bowel injuries, ureteral injuries, leaks, etc. The “minimum-standard” surgeon has multiple bowel injuries, 20% leak rate, long length of stay. He continues to operate unrestrained. It is unconscionable in my opinion, but the article was no surprise. Ready for the kicker? He proctors for the company who makes the robot! I am not interested in that and declined to do so, as the company is looking for rubber-stampers to “greenlight” naive surgeons and get as many people using the machine as possible so they can sell more disposables (and maybe another machine). Make no mistake the company is not interested in quality, they are interested in quanitity– can't blame them they are running a business. We as doctors and hospitals should be the advocate of the patient. A good operation is a good operation open or robotic, a bad one is a bad one. It depends on the operator not the machine.

Emphasis in bold was mine. This is a complex issue, but it seems like some things are simple and obvious – we need good training and good process. But how does a doctor get experience if you shouldn't let an inexperienced surgeon operate on you?

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