The other day I was speaking with two gynecologists who both ‘loved’ the surgical robot. They beamed about the remarkable skills the robot had granted them. When I asked, “so what kind of cases do you do with the robot,” their reply was remarkable.
Many years ago there lived a quirky man named Immanuel Kant. He never married and never strayed very far from his home in Prussia. While many physicians cock their head like my quizzical dog at the name Kant most folks are aware of some of his philosophical positions. In ethics Kant is most known for the ‘Categorical Imperative.’ There are a few iterations of the imperative but the easiest to digest and most relevant to my discussion goes like, “never use another person as a means to an end.” Persons are ends.
Hospital credentialing is a screwy thing. Once you become a licensed physician you still have to convince a hospital to allow you to practice medicine within their facility. The amount of convincing is not a fixed matter. In other words two hospitals could have vastly different ‘rules’ about what you have to do to prove you can do what you say you can do. For instance when I was first asked to fill out my hospital privileges I needed only to mark off what I thought I might want to do. There was no need for ‘proof’ that I could do the things I marked, I simply needed an interest and a credible residency diploma. Since that time things have changed but not uniformly; there are still big differences across hospitals. Thankfully hospitals are getting a bit better at this process but they are not immune to bias. For example, in some hospital’s enthusiasm to get a robot program going, the ‘rules’ about credentialing have been in many cases too loose.
Back to the two gynecologists and their robot tales. Citing hospital credentialing rules that stipulated performing a minimum number of cases per month (arguably better than usual credentialing rules but still problematic) these gynecologists admitted at times they utilized the robot in cases they could have otherwise done without it just to satisfy the rules. What would Kant say?
The enthusiasm for all things minimally invasive has at times bordered on absurd. Natural orifice surgery (i.e. removing the gallbladder via the vagina) is one brand of minimally invasive surgery that has caught the imagination of some in medicine and perhaps one day it will be mainstream. The irony amidst this hubbub is that minimally invasive surgery (notwithstanding vaginal surgery) hasn’t always been better than ‘open’ surgery. For instance, there was one randomized surgical trial with patient and post-operative assessors blinded to the surgical access that documented an open gallbladder removal was superior to the laparoscopic (key-hole) approach. Go figure. Insofar as the robot is concerned, one well-done randomized surgical trial comparing it to the traditional laparoscopic approach demonstrated the robot took more time, cost more money and was associated with more pain at every postoperative assessment. And yet the robot appears on highway billboards promoting a hospital’s commitment to ‘technology.’ Go figure indeed yet the public seems to be receptive to these sorts of inducements.
So now, given what I’ve said so far, what would Kant say about these gynecologists’ reasons for using the robot? Curiously the argument is echoed in any sentiment that poses the physician benefit as the driver of a technologies adoption. Better physician comfort, while important but dangerously subjective, dances closely to confusing means and ends. In the cases of quirky credentialing rules, is the patient’s best outcome foremost in a decision to use the robot (or any technology) that is ultimately based on criteria outside of the clinical scenario?
Sadly as I mingle between academic and nonacademic physicians in diverse settings the reasons to adopt the robot (or any medical innovation) shared among them are not unique. Indeed some version of this tale is often the central impetus for adoption. There is abundant evidence that peer perception is at the root of many of our behaviors. Medical innovators know this and proffer tales of ‘important’ and ‘prestigious’ physicians who have adopted or endorsed their device. Few have been as successful at this game as Intuitive Surgical the makers of the daVinci robot. Adopting the robot to gain market share or notoriety or device access because of credentialing rules all disappoint the Categorical Imperative. Maybe medicine should take a cue for Kant’s isolationism and eschew industry representatives?
What are your thoughts?
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