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.
There are days when laparoscopic surgery is a breeze. The anatomy is perfect. The view is beautiful. Your assistants are thinking three steps ahead of you. In other words, the way surgery happens in your dreams
And then there are days when it isn’t going that way. The anatomy is distorted and confusing. There is bleeding that continuously distort your view. Your assistants are struggling. You are quickly becoming unhappy and want nothing more than for the surgery to be over and the patient to be well.
I have had many of both kinds of days. Over the years I have been operating, I have identified a few things that tend to have happened on the latter kind of days, and hope to pass a few of those things on. So if you find yourself struggling with laparoscopy, consider whether one of these things is going on.
Yesterday I was going through my closet and separating out a lot of clothes that I no longer wear to give to Goodwill. Among the many things I selected to never see again, I noted a tie that I wore to my original medical school interviews. An wow.. it was a problem. Did I really wear this? I then decided to actually put together the outfit that I wore to my interviews. And now I realize… its a miracle I ever got in.
I grew up in Oregon, where no one ever wears a tie, and no one ever dresses up. When it came to interview for medical school, I truly had no appropriate clothes. I consulted my father, who suggested the outfit you see here:
Note the tie that is missing the material in the back to allow the tie to line up. No problem there.. just use a paperclip. Really. While my father was trying to lead me in the right direction, little did I know this was the same father who fifteen years later would wear a tee shirt to my wedding.
So basically, I walk into medical school interviews looking like this:
Note the rather ill-fitting sport jacket, Mathlete regulation length tie, and unmatched pants that are too small. Ignore the pleats, they were actually in fashion then.
But how was I to know? I was a computer science major and a total geek. This was dressing up big time. I was fully expecting that when I went to interview I would be looking sharp.
Not so much. When I arrived to my first interview at Baylor College of Medicine I found myself terribly underdressed compared to all the Brooks Brothers suits sitting next to me. While I looked maybe all right, they looked good. And more importantly, they all looked the same, and I looked different.
And perhaps that was my mistake, in that this was what I was actually going for. I knew that a suit was the right thing to wear, but I had a rebellious streak in me that said ‘screw that! I don’t need to buy and wear a suit! What matters is my brain and what I have accomplished!” I also had a bloodstream that ran with Oregon blood, where most people respond to a person in a suit with the comment “so who died?” And so I proudly wore clothes that looked right out the closet of my University of Oregon math professor Schlomo Libeskind, who inspired my love for higher mathematics and modeled wearing beltless polyester pants up to his nipples.
Fortunately, I survived the process and indeed was accepted to medical school, though not as many as I thought I should have given my academic record. As I was looking back in this during residency interviews, I decided that this time was not going to make the same mistake twice! I was going to wear a suit!
And I chose this:
My mother had found it at a thrift store and extolled its beauty. It was in fact a suit, and it was in fact from a fine Italian brand. Furthermore, it was a suit that when new was quite expensive.
But what it was not was a suit that fit me. It was way too big then, just as it is today. Furthermore, being found at a thrift store, it was in fashion twenty years earlier, not at the time it was being worn. It was also brown, which still set me aside from all the other blue and black suits that interviewed for residency with me.
I did get some “nice suit” comments followed by furtive glances to the side or floor. As a person who now plays a lot of poker, I now realize that those comments were purely ironic. I also heard “bless your heart” in the South a number of times, which by the third year of my residency in Charleston,SC I knew was actually an expression of kind condescension.
Fortunately, despite this suit, I got into the residency I wanted. Apparently being the rare highly qualified male applicant to an OB/GYN residency was worth more than the ill-fitting suit cost me. And at the end of my residency, the chairman took me to a fine men’s store with the invitation “Son… they’re having a sale.. and you need a nice suit for your faculty interview.” ”But I have a suit!” ”Son… you’re going to a be a faculty physician… you need more than one suit.”
* * * * *
At the time, I didn’t think this dressing up business was important, but now as a faculty member I realize that it was. There is no doubt that on the days that I interviewed in those clothes, the faculty were laughing about me at the applicant review sessions. I have no doubt that at my medical school interview they were saying “how about that Fogelson guy with that sportcoat and no belt?” And at my residency interview I’m sure it was “how ’bout that huge brown suit guy!”. Of course, does that really hurt a person? As a person who interviews and ranks applicants, I can say that it almost certainly does. An applicant has only a few minutes to convince someone that on a very subjective level that they deserve to be in the medical school or residency. In the end, you hope that your interviewer is talking about how smart and accomplished you are, and not about how you were dressed. It seems so superficial, but that doesn’t make it not true.
So the truth is this: When you interview for a job in medicine, your clothes should be invisible. They should be well fitting, relatively conservative, and ordinary. They should be neither particularly bad nor the height of fashion, leaving your interviewers nothing to comment on other that what really matters – the person wearing the clothes.
When I interviewed for medical school, I interviewed at 8 schools and was accepted at one. I had great MCAT scores and way more medical experience than could be expected of any applicant. If I had been dressed like this I probably would have gotten into a lot more schools:
Quite some time ago Micky Morrison, a physical therapist and author, send me a copy of her book Baby Weight. I promised to give it a prompt review, and then promptly put it on my desk for about six months. As the fans that are still aware of Academic OB/GYN know, the blog and I have been pretty quiet. I did a fellowship, and now am building a new practice.
But now I have finally got to the book. And it is BABY WEIGHT!
As a physician, I occasionally encounter patients who feel like they know a great deal more about medicine than they actually do. Sometimes its a family member of a patient. Occasionally they are right, in that they have a particular cache of knowledge about a particular condition that surpasses me. In those circumstances, such patients or family members are able to augment their care. Far more often, however, their expertise is far less than they think.
For example, I once cared for someone who clearly needed a blood transfusion. A family member was in strong opposition, mostly because that family member was Jehovah Witness, even though the patient was not. That family member presented all kinds of information about alternatives to blood transfusion, and clearly right from a pamphlet they had read. At a fundamental level, said family member believed that there was always an alternative to blood transfusion and it was never actually necessary.