The invasion of the surgeon robots.

Health and medicine explained.
June 27 2008 12:57 PM

Dr. R2-D2

The invasion of the surgeon robots.

A robotic surgery demonstration. Click image to expand
A suregeon remotely controls an invasive robot

Remember how much fun the future used to be? Everyone trim and twinkle-toed in their one-piece jumpsuits with plenty of robots to do the work then mix the cocktails. And yet, despite the decades of excitement, the promised robot epoch remains mostly out of reach. Even the world's leading futurist, Pixar-Disney, in the new movie Wall-E, has placed the date of robot domination 600 years from now.

There is one realm, however, in which robots really are joining the gang: the operating room. It turns out that Americans love to be operated upon by them. Last year, robots participated in thousands of surgeries, and the years ahead promise even more choices. Cancer surgery, heart surgery, brain surgery, you name it—R2-D2 awaits your call. The robots even have their own medical journal (OK, it's run by the humans who operate the robots, but egad!).

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The early buzz on the robot street was that all the health care players had found a winner. Insurance companies were ecstatic because robotic surgery resulted in shorter hospital stays (and therefore larger insurance-company profits). Hospitals loved the idea of looking ultramodern and futuristic. And robot makers, hawking a product at about a million bucks a pop, were in raptures.

What about patients? People often distrust newfangled doodads, and yet rather than being spooked by the prospect of a piece of metal drilling and sawing and sewing in their abdomen, they generally have been eager to sign on. We don't yet let robots wash the car or mow the lawn, but dissect out a cancerous prostate? Sure, go ahead. And fix that heart valve while you're in there.

Before calling the invasion of the robots a total success, however, there's a big fact left to examine. How have patients actually fared once they've left the hospital? Not how quickly were they discharged or how little blood did they lose during the procedure, but what course did their disease follow? The reason for the surgery, after all, was to extend or improve a life.

The results are just now trickling in, and the answer is: maybe not so good. A recent article in the esteemed Journal of Clinical Oncology examined 2,702 Medicare beneficiaries who underwent prostatectomy from a variety of techniques. The authors compared outcomes from a laparoscopic approach that frequently used robots with surgery using the traditional configuration of surgeons and nurses stationed around the operating table. Although the robots performed better on the early returns—outcomes like length of hospital stay and postoperative complications—their patients' cancers fared worse in the long run. Specifically, the laparoscopic group was more than three times as likely to require additional cancer therapy, such as radiation or hormones, than those operated on by hand. As an accompanying editorial suggested, perhaps there is value in the human act of looking at the affected area of the body and touching the surgical bed, of mulling and worrying. Sure, we Homo sapiens are inarticulate, inexact, forgetful, and have bad posture and unsettling cousins. But we also may have some gift that isn't easily reproduced by robotic motion.

This study has important limitations—not all laparoscopic surgeries involved a robot, and only Medicare patients were examined. But a critical difference between this and other, more optimistic studies is that this time the data came from an objective source—boring Medicare claims—rather than from an impassioned true believer reporting on the wonders of his or her fancy-schmancy innovation. The medical literature is rife with publication bias, the tendency to report only good news. After a while, small, sunny reports pile up until one day someone decides to look at the entire set, as in the article I just linked to. This approach may be conducted as a formal meta-analysis with strict rules and restrictions or as a friendlier-sounding literature review. Such a summary promises a definitive bulk and heft that the individual studies lack. Yet if each of the component parts shares the same chirpy bias—robots are great!—then their sum serves to amplify, not neutralize, the same initial misstep.

Weighed against all the cheering, the Medicare study may not dim robo-lust, at least not until it's replicated. In the meantime, it's worth pondering how far the enthusiasm for robot surgery strays from patients' oft-stated desire for a caring personal physician who holds their hands and remembers their kids' names. Medical school curricula have been retrofitted to teach young doctors how to show emotion, how to listen, how to be empathic. I once had to watch a movie that instructed me on how to nod my head thoughtfully. Compassion is supposed to be a pretty big deal. But what chance does human warmth have against the world's great silver hope?

And herein lies what's most unsettling: Everyone seems relieved that the robots are winning. The ceaseless pounding of the (automated) victory drum has worn us down, made us doubt our own value. Science has long been a tense tug of war between two caricatured groups. On one side stood the nerds with their homemade rockets, plastic pencil pocket guards, and dopey horn-rimmed glasses. On the other slouched the hippie-dreamers, reading Kierkegaard and pondering the imponderables. For the longest time, the dreamers were way, way ahead.

But the advent of robot surgery signals a shift in the balance of power. Now the nerds, who previously had been content sending rockets to Mars, have seized control of that most sacred prize, the human being. Our future suddenly is in their heartless hands.

Kent Sepkowitz is a physician in New York City who writes about medicine.