Last night I had the pleasure to watch an HBO special documenting a masterclass given by singer Josh Groban to three young music students. Over the course the show, Groban coached the students through composition of an original song, and it culminated with their performance of a song that had not existed a week previously at his concert in Chicago. It was a great show that I quite enjoyed, and if you like Groban or music, you should check it out.
The show also made me think quite a bit about how my job teaching residents is quite a bit different than the job most teachers have.
Medicine is a strange career, in comparison to most, in that a doctor does not go on their first true job interview until they are nearly 30 years old. Prior to that, its really just trying to get into college, then trying to get into medical school, then trying to get into the right residency…. but never really interviewing for a job, per se.
My first job interview was with Dr Kenneth Ward, then the chair of the University of Hawai’i department of obstetrics and gynecology. I was interviewing for an academic position, and the interview seemed to be going pretty well. We both liked technology, and were both Apple fans, so there was a fair bit to talk about other than just the job. Overall, we seemed to hit it off.
Then he asked me a serious question.
“So Nick, what was your greatest accomplishment in residency?”
This is an edited video of a robotic hysterectomy and salpingoopherectomy in a patient with stage IV endometriosis, with bilateral endometrioma, cul de sac obliteration, and severe retroperitoneal fibrosis. The video demonstrates ureterolysis, dissection of ovarian vessels from the ureter, and management of colpotomy in the setting of dense adhesions.
For clinical consultation with Dr Fogelson, call Emory University Department of Obstetrics and Gynecology (404) 778-3401
This week in the news there have been a number of articles about a new technology that has allowed the creation of an embryo from three parents, and boy it is creating controversy.
Three parents you say?
Yes. Of a sort.
The case in point regards a woman who unfortunately had a child with a deadly mitochondrial disease. Mitochondria are organelles (“small organs”) inside each of our cells where ATP, our primary energy source, is made. Mitochondria are special in that unlike other organelles, they carry their own DNA. In the case of this woman’s tragically afflicted baby, defective DNA that could not support much life.
Geneticists have developed technology to create an healthy embryo without the defective mitochondria by placing a nuclei from the woman’s mitochondrially defective egg into a donor egg, after removing that egg’s nuclei. They then fertilized the new proto-egg with the husband’s sperm to create a new embryo. In essence, the egg had three parents – two in the nuclei, and a third one in the mitochondria.
And the world shuddered.
From all corners were cries of “we’re playing GOD!!!”. “We are altering the human race!!” “We’re no better than Mengele!!”
Most of this comes from a bright line we have put around genetics research that says we will not genetically engineer human beings. Legitimate bioethicists have felt that this is something we should not do, because of a ‘slippery slope’ towards eugenics. Religious radicals are just uncomfortable with advancement in science in any kind. They say it is because it is against God, but I think it is because a true understanding of how the universe works deprecates the validity of their religion, and thus sparks a crisis of faith.
But either way, most people think that manipulating human DNA is unethical.
I, for some reason, don’t see it this way. In fact, I couldn’t be happier that we have made this leap, and hope we keep leaping. We are coming to understand how we are put together, and in such we are coming to understand how to manipulate that process. That is exciting, not concerning.
We are not “Playing God”. For us to be “Playing God”, a “God” would have to have been the reason we came to be on this earth. And unequivocally, it is not. The evidence for evolution is so unbreakably strong that to claim that we are here because of “God” is purely ignorant. Humans are on this earth because our genes were selected for over millions of years, not because somebody put us here. If you believe in God, fine. But please don’t hold humanity back from our future by claiming that we are breaking your religious rules.
Even worse is the claim that to genetically engineer a human is akin to Nazi experiments. True, Hitler wanted to manipulate the future of humanity. But he didn’t want to do it by changing the genetic information of the future. He did it by murdering the people who were already here. To claim these are the same thing is an affront to geneticists, and is too good for Hitler.
In truth, I am absolutely head over heels excited to hear that we were able to eliminate a deadly genetic disease from a family through genetic means. What this means to me is that we are actually CURING disease, not just treating the symptoms that it produces.
Evolution is something that is terribly misunderstood. Its detractors really don’t get how it works. People who don’t understand it think it is about the selection of individuals over others, and thus don’t believe it could ever have ended up in us, but that is not really how it works. It is the selection of GENES that drives evolution, not the selection of individuals.
The problem in this case is that mitochondrial genes do not reproduce sexually, but are rather copied directly from their parent mitochondira, and as such they do not evolve. As such, problems in the mitochondria are passed on forever, never changing except by random mutation.
But now, for the first time, mitochondrial DNA is evolving. Perhaps not by natural selection, but it is evolving nonetheless. And that is exciting.
Don’t take this to believe that I am ignorant of the potential problems. But they are technical, not ethical. Obviously we can not open the doors to unlimited human experimentation, but this is a first step, and it is a good one.
Here’s a new Emory video featuring yours truly.
As I rolled into my office this morning I noticed that my white coat was looking a little dingy. Fortunately, my AA ordered me a bunch of coats so I always have some hanging up, fresh from the cleaners. Usually she has to tell me to switch them. Occasionally I notice myself. Either way, I don’t tend to walk around with a coat that isn’t at least mostly white.
But it wasn’t always that way. As a resident, I had a habit of finding out just how brown a white coat can be. It was hard to tell for me, as the change was very gradual. But a few years into a residency, I could stand next to someone with a truly white coat and the difference was, well, ghastly. But now it is different, and while I have to give my AA credit, in truth the credit goes to my third year REI attending, Dr John Schnorr.
I started my REI rotation early in my third year. Effectively, this meant that the two white coats I had been given at the beginning of my internship were somewhere between yellow and poo. I walked into the Taj Mahal office, as REI offices tend to be, and presented myself to Dr Schnorr. He gave me a funny look that I didn’t quite pick up on. He then proceeded to go over all the rules and responsibilities for the rotation, as would be typical for the orientation.
We had a great first day. At the end of it, I could tell he was a little uncomfortable about something. He hesitated, then he came out with it.
“Do you get your coats laundered?”
This was a very polite Southern way of saying “Your coat looks like shit”
As if I had to say it.
But then he said the greatest thing.
“Just throw your coats in our laundry bin…. our people will launder them for you.”
So I did, and was forever changed. When I got that first laundered coat, all bleach white and starched, I never looked back.
So residents – take your coat to the cleaners from time to time… its only seven bucks, but it looks like a million.
This month ACOG released a statement on Robotic Surgery, generally negative towards the development. They propose that robotics does not offer a proven advantage in benign gynecologic surgery, and increases cost.
Per the statement “If most women undergoing hysterectomy for benign conditions each year chose a vaginal or laparoscopic procedure—rather than TAH or robotic hysterectomy—performed by skilled and experienced surgeons, pain and recovery times would be reduced while providing dramatic savings to our health care system. Conversely, an estimated $960 million to $1.9 billion will be added to the health care system if robotic surgery is used for all hysterectomies each year.”
This morning a large cadre of minimally invasive surgeons released a statement of response, accusing ACOG of not being supportive of minimally invasive techniques and misinterpreting the data on robotics.
Here’s my take on the issue:
I am a surgeon that focuses on minimally invasive techniques and gets a lot of referrals for difficult cases. I’ve been doing robotics for about two years now, and have done enough cases (over 100) that I feel like I can make a pretty objective assessment of its utility in what I do.
As Intuitive Surgical will be happy to tell anyone that listens, robotics has quite a few advantages.
The ability of the robot to move with wrist-like motions allows laparoscopic maneuvers that are difficult if not impossible with straight stick laparoscopy. This allows one to do surgery in very small delicate areas that are much harder to address traditionally.
The vision allowed by the robot is far superior to traditional laparoscopic vision, for 4 reasons: 1) image fidelity is better than most traditional equipment 2) 3D vision allows one to see relationships between structures far better 3) the screen is so close to your face that it fills your whole field of view, creating an immersive “I am the robot” experience and 4) you control the camera and don’t have to depend on your assistant to show you what you want to see.
The ability to pass energy through both primary instruments creates a surgical flow that is difficult to match with traditional instruments. The fact that one can cauterize every surface that is cut tends to lead to bloodless surgery. This can be done traditionally as well, but its a bit more difficult to achieve the same result.
Long laparoscopic surgeries require a surgeon to stand in a way that is eventually painful to the back and legs. Robotics is quite comfortable for the surgeon, as he is sitting in a ergonomically superior position.
All of this together allows one to tackle much more difficult cases than one might have tackled with straight stick, such as stage IV endometriosis with obliterated cul-de-sacs, huge uteruses, or cases that require extensive suturing. As such, robotics has the potential to turn cases that otherwise would have been abdominal cases into laparoscopic cases.
There is potential to do surgeries through a single site using the robot, which is a cosmetic advantage over multiple port surgeries.
And here is the downside:
The robot is a tremendously complicated piece of equipment that requires a very skilled team to operate efficiently. Without that team, the use of the robot adds a huge layer of complexity to a surgery. With that team, it still slows things down. While one may be able to do the operative portion faster, the setup time for the room and and early part of the surgery is significant and will slow most cases down overall. A ideal team may mitigate this completely, but such a team I have never seen in an academic center.
The robot is extremely expensive, both to buy and to maintain. It costs between 1.5 and 2 million dollars, and several hundred thousand dollars a year for a service contract.
One usually needs more port sites to do robotics than traditional laparoscopy.
The robot breaks down from time to time, sometimes in the middle of a surgery. While these problems inevitably get resolved, it is a remarkably unpleasant experience for all involved. A two million dollar machine with a two hundred thousand dollar a year service contract should not break down at all.
The robot is sold and serviced by a company that does not have an objective view of their own technology. They aggressively market their product directly to patients, and even more so to the robot trained surgeons. They do not seem to see the reality of their product, which is that it is very useful for a subset of laparoscopic surgeries and a hinderance to another subset. They prefer to think about it as an improvement to all laparoscopic surgery, which it clearly is not.
My feeling is that ACOG’s statement is a response to the tremendous proliferation of robotics throughout benign gynecologic surgery without a clear evidence base to suggest that this level of use can be justified. I agree with that part. A lot of surgeons are using robotics to complete cases that could have been done via traditional laparoscopy or vaginal surgery, which is not right. The entire point of the robot was to convert open surgeries to laparoscopic surgeries, but in benign gynecology it is being used for far more than that. This drives up costs at minimal to no benefit to patients.
Some argue that robotics allows a surgeon who is not a particularly skilled laparoscopist to do more difficult laparoscopic surgeries. I think this is true, but at the same time I am not sure that is a good thing. Surgery is done best when it is done by people that do a lot of it. If one does a lot of laparoscopy, one gets good at doing a lot of things with or without the robot. At that point many mild to moderate difficulty laparoscopic surgery is most easily done without the robot.
Right now my hospital has two robots at one center and is about to buy a second at our other site. The drive to have multiple robots is because of demand for time on the robot. While this seems appropriate, I have to ask myself whether these marginal cases that justify a second machine actually cases that require robotics to be completed laparoscopically. If not, then the cost is not very justifiable.
I love working with the robot, and get a real feeling of accomplishment when I am able to complete a robotic case that I know I never would have been able to do through traditional methods without a laparotomy. I have done many of those. But having done over 100 robotic cases, a 10 week size hysterectomy done robotically does not give me that sense of accomplishment. I get that sense of accomplishment by doing that case vaginally or via traditional laparoscopic surgery, being out of the room in two hours and with far less expensive toys.