We venture to suggest that very few surgeons expressed or even felt a need for a surgical robot until Intuitive Surgical started aggressively marketing its da Vinci surgical robot. A few years later, there was growing clamor for the robots, even though there was no overwhelming evidence that surgeons with robots were achieving better outcomes than surgeons without.
Many expensive and, at best, only marginally beneficial technologies are present in the operating room because manufacturers pushed them on surgeons. While a great deal of money is wasted on many products, occasionally a new technology proves its worth. A thorough assessment of new technologies would prevent many unnecessary purchases.
As a young chief resident, one of the authors was tasked to analyze a new set of hospital beds. He found that each had only marginal advantages over the existing beds, but the margin came at so great a price he decided the cost-benefit balance did not justify their purchase. There was a similar event in his field, urology, where balloon dilatation of the prostate was pushed in the early 1990s but, eventually, was shown to be no better than simpler and cheaper treatments. The weight of the cost-benefit balance was all on the cost side. Questions remain about the benefits to patients of robot-assisted procedures, or certainly about the costs and benefits.
About three years ago, one of the hospitals with which we are associated bought a power-driven anastomotic device that fit on the end of a scope. Its touted capabilities turned out to be not so, and some $75,000 went down the drain. That was only the tip of an iceberg: For every step forward in medical and surgical technologies there are probably four or five large capital investments languishing in a hospital basement.
It seems, then, that technology can drive up health care costs dramatically, often without an equivalent dramatic improvement in patient outcomes.
On the other hand, the original 1980s lithotripter — a room-sized kidney stone disintegrator costing $2 million in 1980s dollars — offered such clear benefits to patients that it practically sold itself and, over time, became refined to the point where today van-mounted mobile lithotripters costing around $500,000 are delivering excellent service to patients who need it. Yet it's also delivering a costly service to many patients whose condition could be remedied with less expensive treatments.
Perhaps the silver lining to the surgical robot is that it has helped to develop an environment that supports and encourages surgeons who want to advance their field through technologies. Such surgeons already have led us through the revolution of minimally invasive surgery and now may be moving us toward an era of surgeon-less surgery.
The surgical robot also has helped create a new generation of patients who are comfortable being treated by machine, just as airline passengers are comfortable knowing that their airplane is on autopilot for most of its journey. Indeed, the savvy passenger, knowing the reliability and accuracy of today's autopilot vs. the frailties of human pilots, would prefer that the autopilot handle takeoff and landing as well.
Assessing Costs and Benefits
Technology vendors contribute both to progress and to the cost of health care. Doctors also contribute to both by being ethically less inclined to worry about the cost portion of the cost-benefit equation when there is a potential benefit to the patient. Few of us would contest that technology has been and is a great engine of advancement for medical care; it is this fact that makes physicians and hospital administrators so vulnerable to its push. No one wants to be left behind, and no one wants to pass up the latest great idea. But it is difficult to figure out which will be a success and which will fail and, given the accelerating introduction of new technologies, the time for figuring grows ever shorter.
Surgeons could use some help. Perhaps clinical engineers could devise and run a statistics-based program to assess probable vs. touted capabilities for a technology before it is purchased, or at least before it is purchased in quantity. Alternatively, or in addition, they could develop a matrix plotting cost on one axis and the perceived degree of patient benefit on the other. Technologies that fall in the low-cost, high-benefit category would be easy winning picks; those in the high-cost,low-benefit quadrant would be easy rejections. The real conundrum would be how to decide on technologies that fall in the low-cost, low-benefit and high-cost, high-benefit quadrants.
There are consultant services that long have supplied such assessments (the Health Care Advisory Board is one we know, but there are others). They also offer guidance in establishing technology review committees. Yet the consultancy is rejected on account of its cost, or the guidance goes unread or is simply ignored, or the committees never get formed or don't last long under the pressure of other things to do. Whatever the cause, hospital basements continue to fill with expensive junk.
Could it be that we ignore technology assessments because we believe that acquiring junk (along with the occasional pearl) is a price that must be paid for progress in surgery? Certainly, we will make errors as we seek to improve medical care, but better assessment of new technology could save hospitals money.
David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. He is also a regular contributor to H&HN Daily and a member of Speakers Express.
J. Edson Pontes, M.D., is a urology professor at Wayne State University School of Medicine in Detroit, and he practices at the Karmanos Cancer Institute. He is also the head of international services for the Detroit Medical Center.
Donald W. Weaver, M.D., is the surgery department chairman at Wayne State University School of Medicine and surgeon-in-chief for the Detroit Medical Center.
Charles J. Shanley, M.D., is a vascular surgeon at William Beaumont Hospital and professor of surgery at Wayne State University School of Medicine.