Friday, February 17, 2017

Will robots eliminate the need for surgeons?

A medical student from Germany emailed me saying he had always wanted to be a surgeon, but someone told him that by 2030 surgeons would no longer be needed because robots would be doing all the operations. He worried that after years of studying and hard work, he might lose his job to “R2-D2.”

He mentioned IBM’s Watson and a recent paper that appeared in the journal Science Translational Medicine about a robot that can handle and suture bowel.

He asks, “What do you think about the future of surgery?”

Thank you for your email and the link to the paper.

I read the paper and was amused by its title "Supervised autonomous robotic soft-tissue surgery" which is an oxymoron. The definition of autonomous is "acting independently or having the freedom to do so." This “supervised” robot is not really autonomous.

The robot is capable of performing a nearly technically perfect intestinal anastomosis but still needs a human surgeon to open the abdomen, prepare the bowel for the procedure, tidy up, and close. I'm not sure that this is any different than when surgical staplers were introduced. This robot is simply making the operation easier and possibly more precise.

Surgeons will still be needed in case the robot makes a mistake like causing bleeding while placing a suture near the mesentery. If bleeding in that area is not promptly controlled, a large hematoma can develop and possibly compromise the blood supply to the anastomosis. And will the robot be able to decide who needs an operation and when to do it?

One worrisome byproduct of surgical stapling is that many graduates of residency programs within the last 15 or 20 years have little experience in performing a hand sewn bowel anastomosis. What will they do if the hospital runs out of staplers? Soon, I guess they could consult the (somewhat) autonomous robot.

I have written about automation and the erosion of surgical skills. This problem also affects pilots. I have also addressed the concept of  robots operating alone. I don't see it happening any time soon.

I think there will always be a need for surgeons. Even the smartest robot is going to have some trouble dealing with a trauma patient who is hypotensive.

The future will take care of itself. In the 1980s, people were concerned about the demise of general surgery. Opinion pieces with titles like “Will the general surgeon become extinct?” and “Is general surgery a dying specialty?” appeared in major journals like JAMA and the World Journal of Surgery.

Then in 1990, laparoscopic cholecystectomy opened the door to a whole new area of general surgery that no one had ever dreamed of.

Good luck with your studies and your surgical career.

Tuesday, February 14, 2017

Can a cop’s baton accidentally slip into a man’s anus?

I doubt it.

A French police officer has been charged with rape after a black man who was being arrested suffered severe anal injuries.

After witnessing an officer slap someone, the 22-year-old had allegedly approached a group of policemen. The victim claims he was handcuffed, called names, and beaten. He says his pants were lowered and he felt pain in his buttocks.

At the police station another officer noted that he was covered with blood. He was taken to a hospital and diagnosed with the anal trauma which required “major surgery” including a colostomy. The family was told incontinence may result.

Doctors said the injury had been caused by a police baton which had been forced into his anus.

The Washington Post quoted the findings of a police investigation: “The violent sodomy was accidental and occurred when the officer’s expandable baton happened to slip into the victim’s anus.”

According to another story, “a French police union spokesman said there was no evidence so far that ‘the truncheon was actually introduced’ into the victim's rectum. And if that actually happened, it was likely done ‘accidentally.’”

A third story said, “a lawyer for the officer charged with rape said ‘the blow had been carried out in a totally involuntary manner, without his being aware of any injury.’” The word “his” must be referring to the officer because I have no doubt the victim was quite aware.

Based on my 40+ years of experience as a surgeon, I can assure you the police version of the incident is highly implausible. A patient who does not wish to undergo a rectal examination by a physician with a gloved and lubricated index finger can easily prevent it from occurring by voluntarily contracting his anal sphincter and gluteus muscles.

I would imagine a healthy 22-year-old man would react in exactly the same way if a policeman’s baton “happened to slip” with the end anywhere near his anus.

The incident has sparked many protests in France and has been widely reported by news media. Of the several accounts I have read, not one has asked a surgeon to comment on the nature or possible cause of the injuries.

Bottom line: A police baton slipping into a man’s anus is about as likely as a man accidentally falling on a woman and penetrating her.

From International Business Times
Thanks to @Tosk59 for the tip on the International Business Times story.

Thursday, February 2, 2017

Yet another new medical TV drama

“'The Resident’ follows an idealistic young doctor who begins his first day under the supervision of a tough, brilliant senior resident who pulls the curtain back on all of the good and evil in modern day medicine.” So says the article announcing Fox’s pilot for a new medical TV show.

As opposed to all the other medical dramas, this one features an idealistic young doctor and a tough, brilliant supervisor. How original.

I tweeted the show's premise and got several humorous replies prompting me to write this post.

There is no such thing as an original medical show. Original would be a resident sitting in front of a computer 75 percent of the time and then leaving the hospital in the middle of a great case because of work hour restrictions. While at home he plays video games for five straight hours.

Someone wondered if “The Resident” would find romance—possibly in a convenient storage closet. I wouldn’t know about that because I trained at a Catholic hospital.

Another asked if there would be a tough staff with soft hearts, a hospital administrator who put profit before patients, a second-generation physician who cracks under pressure, and a renegade doctor who breaks all the rules but saves the day.

What about a show with overworked, stressed, but oh-so-average attending physicians and idealistic, but basically inept residents?

I’d like to pitch an idea. It’s called “The Administrator” and follows an idealistic young deputy assistant junior vice president who begins his first day under the supervision of a tough, brilliant hospital CEO who pulls the curtain back on all of the evil and none of the good in modern day medicine.

Think of all the dramatic meetings involving committees, ad hoc committees, lean, six sigma, budgets, root cause analyses, public relations, whether to buy a third robot, and so much more. True to life, the administrators never leave the C-suite*.

*C-suite (def): A widely-used slang term collectively referring to a corporation's most important senior executives. C-Suite gets its name because top senior executives' titles tend to start with the letter C, for chief, as in chief executive officer, chief operating officer and chief information officer. [From Investopedia]

Thanks to the Twitter folks who contributed: @smootholdfart, @DrDes1970, @geekpharm, @JessicaDeMost, @DrMikeSimpson, @jsekharan, @mjaeckel

Monday, January 30, 2017

Caribbean medical schools: A look inside



Did you know that several Caribbean medical schools provide postgraduate premed courses so students can complete their science requirements? At least one school’s nearly year-long premed curriculum includes 8 hours per day of classroom work, rudimentary general chemistry and organic labs, and a physics lab with 40-year-old equipment. The fee is more than $30,000 cash, no loans. That's a lot to pay for courses that are not accredited and credits transferable only to other Caribbean schools.

The goal of these premed programs is to prepare students to take the Medical College Admission Test (MCAT). However, some schools require only that applicants take the MCAT but do not reject anyone on the basis of their scores.

A former student said, “Little did I know that a [Caribbean school] acceptance was the equivalent of a lottery ticket. They actually attempted to weed us out of the small (and unaccredited) pre-med class! It took me a month to figure it out.” One of his professors told him the administration said not to pass everyone in the premed course into the first year of medical school.

Tuesday, January 17, 2017

More about adhesions and postoperative pain

In November 2016, I wrote about adhesions and whether they are the cause of chronic abdominal pain. I and several surgeons who commented felt they weren't.

Some new information from the February 2017 issue of the journal Surgery is just in. A randomized, double blind, placebo-controlled trial from The Netherlands was originally published in 2003 after one year of follow-up. At that time, there was no apparent benefit from an operation to lyse [divide] all adhesions laparoscopically in 52 patients compared to a placebo operation that involved performing only laparoscopy to assess the extent of adhesions in 48.

The current paper looked at outcomes 12 years after the original surgery was done. Follow-up was available for 73% of the patients—42 in the group who had adhesiolysis and 31 who had laparoscopy only.

The authors concluded, “Laparoscopic adhesiolysis was less beneficial than laparoscopy alone in the long term. Secondly, there appeared to be a powerful, long-lasting placebo effect of laparoscopy. Because adhesiolysis is associated with an increased risk of operative complications, avoiding this treatment may result in less morbidity and health care costs.”

Unfortunately the paper has a few flaws.

Friday, January 13, 2017

"Malpractice" from the viewpoint of a plaintiffs' attorney

Lawrence Schlachter is a neurosurgeon who after 23 years in practice, was forced to stop operating because of a hand injury. He went to law school, became a plaintiffs’ attorney, and wrote a book called “Malpractice.” Although it is intended for patients, physicians might want to read it to learn something about how a plaintiffs’ lawyer thinks.

I’m not surprised that Schlachter cites the heavily extrapolation-based Journal of Patient Safety study claiming 400,000 medical error-related deaths per year and the thoroughly debunked Makary study claiming 251,000 deaths per year due to medical error. He does a little extrapolating of his own and comes up with 562,000 patients per year.

I agree with Schlachter about many issues. He says the best way to avoid becoming a victim of negligence is to take good care of yourself. If you need to be hospitalized, aggressively be your own advocate or have a relative or friend do it. You cannot assume that mistakes will not happen.

Monday, January 9, 2017

How can we instill more confidence in our graduating chief residents?

For over six years, I have been writing about problems in surgical education. My seventh blog post ever was about the negative impact of changes in surgical residency training.

In that post, I cited a residency program director who felt that rules imposed by the Accreditation Council for Graduate Medical Education (ACGME) resulted in excessive supervision of residents who never had a chance to operate independently. Many feel that this is a major factor resulting in 80% of graduating chiefs opting to do one or more years of post residency fellowship.

Excessive supervision continues in 2016. In his presidential address to the Southwestern Surgical Congress, John R. Potts, III, M.D., a former surgical program director and now Senior Vice President of Surgical Accreditation for the ACGME, had a similar observation. He said, “I have personally encountered individuals finishing general surgery residency programs who have never completed any operation—regardless how simple and basic—without an attending surgeon being with them throughout that operation.” [Emphasis by Dr. Potts]