Thursday, June 07, 2007

Return of the robots

Several months ago, I wrote a post on the use of surgical robots to do radical prostatectomies and suggested that the main impetus for using robots was marketing, that the incremental medical value of such instruments had not yet been demonstrated.

In the May 2007 issue of Nature Clinical Practice - Urology, the journal's editor-in-chief, Peter Scardino, makes the same points, but offers substantial more scientific support that I could ever muster and certainly brings more credibility to the issue than I offer. Here are some excerpts:

Patients . . . are . . . seduced by the notion that the machine eliminates human error.

The fundamental measures of quality for any medical treatment are its safety and efficacy, which require meticulous documentation in well-designed clinical trials. Where are the trials that show superior outcomes with [robots]?

Studies that report better outcomes with [robots] that with open prostatectomy are limited to single-institution or single-surgeon experiences . . . that claim superior results compared with their own previous experience.

In spite of the evidence to date, enthusiasts are convinced that [robots are] superior to both laparoscopic and open prostatectomy techniques.

Technological advancements, no matter how compelling, are only as good as our ability to use them prudently and wisely.

6 comments:

Anonymous said...

Paul;
You read my mind; I had been going to ask what you ever did about the robot. This is interesting in view of the fact that one of your own urological surgeons basically told you he couldn't live without the robot, or something like that. It just points up the subjectivity so prevalent in medical practice, and why the elusive goal of "evidence-based medicine" is so critical.

However, this post also relates to your previous one regarding hospitals wanting to be full service and to have competitive equipment. Will you lose business if you don't purchase the robot? (ps does BID do open heart surgery? The da Vinci system is also used for that) The public IS enamored of medical technology; and perception is a hard thing to change.
So what will be your ultimate decision, or are you still waiting and watching?

ps thanks for introducing this group of journals related to Nature" to me; I hadn't heard of them before and checked out the nature.com website.

Paul Levy said...

Our urological surgeons obtain excellent results and offer both open and laparoscopic surgery. Ditto, for our heart surgeons.

As to what will happen on this issue, the jury is still out. Lots of people offered helpful advice on my lastposting!

Anonymous said...

I stand slightly corrected; I checked your post of 2/20/07 and the letter from one of your "leading doctors" mentioned the loss of business BID would theoretically sustain without the robot, and Dr. Savetta commented in favor of it also.

This also reminds me that the evidence that radical prostatectomy is superior to radiation for any but certain subclasses of patients is not even clear yet, either. Personally, I agree with your wait and see approach at the moment.

FINALLY (does this mean I'm defensive??? grin), may I get on my soapbox one more time and point out that one may not read the article you cite without a subscription, once again depriving us of a learning experience. Some day this will change, you editors, like it or not!!!

Sunil said...

While working as bed control manager at Newark Beth Israel Medical Center, Newark, NJ, i had the oportunity to witness admission-discharge process of Dr. Savatta's patients. From the capacity management point of view, the one day LOS of patients with robotic prostatectomies (unless complications arise) had been quite helpful. Of course, these are just my observations but Da Vinci robot was quite extentively used for marketing purposes.
Sunil Krishnan
skrishnan@unityhealth.org

Carmen said...

In case you're interested, I wrote an article earlier this year that makes some of these same points.

www.cancer.gov/ncicancerbulletin/NCI_Cancer_Bulletin_011607/page5

Very interesting blog that I just stumbled across today via the Washington Post.

Anonymous said...

I found your blog when I was researching a business case to buy one of these robots. Ironically, the business case was a 'formality' as there was an absolute pre-determination that we were purchasing one, baring complete proof of disaster. I remain neutral on the impact of the machine on outcomes, but I am very certain that the arrival of the robot is going to cause a disruption in the operating rooms, and impact our already overly-large backlog of cases. It is always a challenge in the business of medicine to balance against the emotions and perceptions of medicine, and not be seen as 'an evil bean counting MBA'(as I was once addressed in a heated moment). My job is to be a steward of the finances that allow the doctors to offer the highest quality medicine to the most people possible, but there are some tides I just have to step off of the beach for.

Thank you for this terrific blog.

-Capital Asset Manager, West Coast