There’s a lot of hype around the first Google Glass operation, performed last week at the Clinica Cemtro in Madrid. Although Glass was used in this instance for training purposes, it doesn’t take much imagination to see its potential for guiding a surgeon. That’s a step which fulfils much of the original promise of remote robot surgery, which we now see in a somewhat emasculated form in the Da Vinci robots, which are arguably adding more glamour than technology to routine procedures.
If we take that mental step towards guiding and assisting surgeons through Google Glass, it leads us to ask the more important question of how we select and train surgeons, and what patients should expect of them. If we want the best manual technicians we may not want to retrain our current surgeons, but look for a new breed. That resonates with George Brandt’s play Grounded, which won awards at Edinburgh this year. It looks at the issues in reassigning fighter pilots to operate drones. It has a magnificent performance from Lucy Ellison and has relevance to many other areas, particularly the brave new world that Clinica Cemtro are letting us glimpse. If you’re in London before 3rd Oct, go and see it at the Gate Theatre.
Let’s look at how those three things come together.
The Clinica Cemtro announcement can be viewed as a PR opportunity. A surgeon somewhere in the world was going to be the first to stream a live operation via Google Glass, the only question is who would be first? I suspect that the delay in this happening is more to do with ethics and patient consent than any limitation of the technology. I applaud the Clinica Cemtro for the way they did this. They pitched it as a training opportunity, where young surgeons could learn about the practice in a far more intimate manner than they would otherwise be able to experience. It builds on video training to make the surgical process more realistic. I’d support the clinic’s claim that it is the closest that other surgeons can get to the practice short of being there as observers in the same operating theatre.
It doesn’t take much of a stretch of the imagination to turn the situation around so that the Glass provides input to a surgeon to help guide them through a procedure. That’s a major step in using input from others to improve the efficacy or efficiency of a surgeon, and it’s is probably a step too far for much of the medical industry. But should it be?
In many ways that step is just a logical extension of what the industry has been doing with medical robots. The genesis of medical robots goes back to the 1980s. At around the same time that the final episodes of MASH were being made, the US Army started pouring money into telerobotics for battlefield surgery in an attempt to put an end once and for all to the photogenic image of the caring, maverick army surgeon. They took the view that it was too expensive, dangerous and difficult to deploy appropriately experienced surgeons to the front line and started funding companies to develope remote surgical robots. Like today’s drone operators, the surgeons could remain on US soil, performing operations over long distance comms links.
It didn’t take long to show that the principle wasn’t practical, but the funding gave rise to two companies selling robot surgical systems – Zeus robotics, and the company that was to acquire Zeus and give us the Da Vinci robot – Intuitive Surgical. Today the Da Vinci is the most widely used surgical robot, with around 2,000 of them performing a total of over 200,000 operations each year.
The original concept of surgeons operating on patients in different countries or continents has proven to be illusory. Today almost all of these robots have the surgeon sitting at a console next to them, manipulating the robotic arms carrying scalpels, tools and a stereoscopic camera. They’re used almost exclusively for laparoscopic or keyhole procedures. The advantage they bring is that they remove the need for an assistant to manipulate a camera in the incision, or for the surgeon to constantly look between a screen and the patient they’re operating on. The robots also have the capability to detect erroneous movements, such as those from shaking hands or slips from tiredness.
However, those are features which most benefit long operations, which are rarely performed with them. Instead the vast bulk of procedures using these robots are prostatectomies. Given a Da Vinci robot costs around $2 million, and has a hefty annual maintenance, it makes economic sense to use them for as many operations as possible, hence their relegation to this specific corner of the surgical hierarchy. That doesn’t stop them being valuable status symbols. There’s no doubt that they’re the modern day equivalent of Monty Python’s “machine that goes ping”.
Which is where Google Glass gets interesting. Putting aside the inevitable objections of the FDA, it enables surgeons to learn and be guided through new or complicated surgical techniques. It feels that it could resurrect the promise of the early telesurgery prototypes, but using technically competent staff to perform the operation. I’m refraining from using the word surgeon, as we may need to rethink the medical hierarchy and how we select and train those who operate on us. I’ve always felt that surgeons should first and foremost be dextrous, but we don’t select them on that basis. Today the system is geared towards children who have been tutored to death to get into medical school. I think it would be far better to select kids who spent their youth making things and developing those manual skills.
Which brings me back to Grounded. It tells the story of a fighter pilot in Afghanistan who gets reassigned to flying a drone from an Air Force base outside Las Vegas. To her, it’s a demotion to the Chair Force. The play makes some very telling points about how professionals react to having their skills used in new ways. It’s an experience that Da Vinci surgeons are already living and which more of the medical profession may soon need to learn.
Should I get to the point of needing my prostate pruned, I’d far rather the nimble fingered technician with a guiding Google Glass than the jaded surgeon reassigned to the medical Chair Force. I’d also like to have the operation done in a national or regional centre of competence where it’s performed daily, rather than a local centre of incompetence. That’s a message about evidence based medicine that needs to get through to MPs and campaigners who cannot understand that consolidation can give better medical results. And I’m not sure I need a $2 million robot to assist the technician.
We should be looking at the Clinica Cemtro operation as an opportunity to rethink not just the way we do surgery, but who we train to do it. It’s not a call to do surgery on the cheap, but to accept the fact that surgery needs craftsmen and consistency more than it needs shiny robots. Watch the video and embrace it as hopeful sign for the future of medicine.