In the current competitive environment, healthcare providers often attempt to separate themselves from their competition by marketing themselves as using the newest technologies for their procedures. This is an age defined by finding the next best thing and the American public responds to this strategy. My personal experience has been in cardiac surgery, but the principles are equally applicable to other specialties, particularly tertiary referral practices.
To the consumer (patient in previous parlance) and referring physician, the word “computerized” implies scientific advancement and the term “robotic” exudes precision devoid of human error. They believe unassailably that “less invasive” guarantees less pain, less personal bodily violation, and faster recovery with similar clinical benefit than “invasive” disfiguring techniques. However, using the newest technology does not necessarily confer a safer outcome.
Change may be either for the better or worse. Responsible introduction of new modalities requires continuous reevaluation. One frustration of scientific investigation is that new procedures which at first look promising, may in time prove inferior. No one can accurately prognosticate if complications or mechanical failure will become evident months or years after the original procedure. The cutting edge can cut both ways.
Even in 2016, the vast majority of cardiac surgical procedures are performed hands-on by surgeons through full-length incisions as has been done for the past 60 years. This has allowed the compilation of a gold-standard score card to which the new must be compared. The public may be intuitively attracted to percutaneous, no-need-for-extracorporeal-circulation Mr. Robot; but all these “improvements” limit the surgeon’s ability to see the entire operative field, correct unrecognized pathology or imperfect repair and obviate proprioceptive feedback. Moreover, these techniques may actually prolong certain aspects of the operation, such as ischemic and pump time. Additionally, they require a degree of superior manual dexterity that may not be universally available.
Interestingly, although the American public is fascinated by the latest technological widgets, many patients will avoid major university teaching hospitals where these widgets would be logically evaluated. There is an unfounded fear that at these institutions patients are subjected to unsupervised care by doctors in training. Aside from this false assumption, it stands to reason that these high volume referral centers can accelerate the learning curve for new procedures as well as being better equipped for unbiased, continuous review of clinical results. Certain stark statistics can bring this concept into focus. There are over 1,100 open heart centers servicing 330,000,000 Americans. By volume, the top 10% do about 500 cases per year. There are 85 open heart centers for 85,000,000 Germans and no center does less than 1,000 cases per year. In fact, the busiest one-third do over 2,500 operations annually. Which set of numbers portends the faster introduction, modification and clinical evaluation of the efficacy of the next “best” thing?
By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton