The underlying premise of less invasive surgery has always been the patient’s interests. From the patient’s perspective, surgical incisions are a necessary evil that should be minimized or eliminated if possible. Patients always choose an operation performed with small incisions over another one that achieves the same goals but uses larger incisions. Less invasive, robotic surgery is not about the needs of the surgeon. Quite the contrary…it is far easier to perform procedures through large, open incisions. Easy operations translate into less stress on the surgeon. Switching from open techniques learned during formal residency training to less invasive surgery usually mandates rapid learning of unfamiliar techniques on your own without the benefit of an experienced mentor. During this prolonged learning process, patient outcomes are often unpredictable. Unpredictability, in turn, often affects the dynamics of teamwork. Habits that evolved over time with the standard approach become outdated and must be relearned. This makes team members feel incompetent, creating problems with morale. Minimally invasive surgeons accept all these risks for one reason: their patients want them to.
Many patients want less invasive treatments of coronary artery disease (e.g. multivessel angioplasty/stenting) rather than open chest bypass surgery even if it might reduce long term survival. Cardiologists often give in to choices that are not the best medical option when the patient has other pressing concerns such as the need to avoid a long recovery and get back to work. Acquiescing to that decision is consistent with the notion of patient autonomy. Surgeons that fail to adopt less invasive methods are an important counterexample. They prioritize the avoidance of their own stress over the demands of (unrealistic?) patients. It is a surgeon’s prerogative to decide what procedures they are going to offer. However, it is not OK for a surgeon to proceed with open chest surgery without letting patients know about less invasive options offered by other surgeons. In doing so, they place patient autonomy at risk.
The novice phase of learning less invasive surgery exposes patients to a period of heightened risk. Much of the risk is unforeseen and hard to quantify but continues until the team becomes proficient. Surgical societies have weighed in on this issue by offering postgraduate training courses that help interested surgeons learn tips/tricks about robotic procedures. These courses are clearly addressing an unmet need because few surgeons get any semblance of robotics training during their residency. But in my opinion, very few hazards of the learning curve are directly caused by a surgeon’s lack of technical skill. Rather the root cause of problems are defects in the systems of care provided at hospitals – the same chronic defects that have caused safety problems for decades but was underappreciated until it was exposed by the unique demands of novel procedures. New skills are required that had not been previously necessary for status quo procedures to appear safe and effective. For example, teams tackling robotic surgery must develop new ways of working together, and develop sufficient psychological safety to learn rapidly through team briefings and debriefings. A high level of political skill is needed to gain the support of stakeholders outside the operating room and weather the inevitable storm of trying to innovate in a conservative environment.
One well proven role for working towards technical proficiency prior to initial clinical cases is that it improves attentional capacity. Surgeons have a limit to how many things they can focus on during a case, because humans have limits to their cognitive bandwidth. Novel procedures like robotic heart surgery that are highly technically demanding can increase the risk for cognitive tunneling, or the inability to maintain situational awareness when a patient is not doing well. In the context of a team with low levels of psychological safety, this can reduce the ability to safety respond to intraop complications that often occur. Technical training prior to operating on a patient helps to automate aspects of technical performance, which then frees up bandwidth and improves our ability to respond effectively to intraop crises.
While these are mandatory skills for leading surgical teams, the fact that they are rare is a system problem rather than a cardiac surgeon problem. First of all, it is common knowledge that surgeons are selected for their technical skills and not leadership abilities. Surgeons rarely get formal leadership training at any point during their career. Secondly, no one else has been able to step up and help the surgeon in this role. Hospital administrators get this training as part of their MBA degrees but don’t have enough credibility with the team to apply their skills to a problem as complex as robotic team development. Hospital credentialing committees require only 2 day training course offered by the robot manufacturer on the basics of using the robotic console prior to a surgeon being approved to perform the first case. On the record, the website of the company has the following legal disclaimer: “Intuitive Surgical is in no way responsible for training in surgical procedure or technique, nor are the training programs described a replacement for hospital credentialing requirements.” Off the record, Intuitive Surgical clearly has tried to have it both ways. They promoted to hospital executives that training would not be difficult. At the same time, they acknowledged in their meetings with the FDA that there would need to be extensive training needed for robotic surgery to be safe. For reasons described in a prior blog post, these training requirements never made it into their final requirements.
Patients that are being operated on by novice teams do not fully appreciate the risk that they accept. Patient surveys show that patients want to know about any special training that the surgeon had prior to performing this innovative surgery. Failure to disclose inadequate training is self-defeating because it betrays the goals of patient centered care, the primary rationale for robotics in the first place. Patients should understand whether their surgeon has deferred the development of any technical and leadership skills required for safety of the procedure. They should realize whether the surgeon intends on acquiring these skills instead on his/her first clinical cases without the benefit of more extensive training a priori. The details of how that conversation might happen are as follows:
Surgeon: I have never done this robotic procedure before. I think that there are benefits that are not possible relative to the open chest approach, which is why I am recommending it.
Patient question #1: OK, I like the idea of a less invasive surgery but I am nervous that you have no experience with it on patients. You have gotten comfortable with the method after a lot of training, right?
Surgeon: I have done all the training provided and required by the company and by my hospital. That included attending some lectures and about 2 hours of hands-on experience on the console getting used to the controls on a cadaver.
Patient question #2: Is that enough training?
Surgeon: Not really.
Patient question #3: Why didn’t you get more training beyond what the company provided?
Surgeon: Not sure if there was any other training available. Even if there was, I didn’t have the time or money to do it.
When Ronald Reagan was being transferred onto the OR table after his attempted assassination, he stopped the team with his famous line: “I hope you’re all republicans!”. If even the President worries about how the OR team thinks of him, imagine how rare it is for the standard patient to drill their robotic surgeon with questions about training. It’s not smart to aggravate someone responsible for your life. After question #1, the patient understands that the surgeon has no clinical experience and is left to assume that training was adequate. Only those disagreeable enough to press on to question #3 discover the shaky reason for poor training. That knowledge changes everything. I can’t imagine agreeing to robotics on me or a loved one under these circumstances. Yet this is exactly what has happened over the past decade more than anyone wants to admit.
Deciding whether to undergo a conventional operation with established results vs. a more technically challenging, novel procedure creates a dilemma for patients. Even at the earliest point in the learning curve, robotic cases still have the potential to reduce the morbidity of surgery but at the possible expense of safety. The choice to accept that tradeoff solely belongs to patients and it is made even harder without all the relevant facts. Laypersons don’t know what they don’t know and completely depend on what their physician is willing to disclose. We know the conversation that the typical novice surgeon has with his/her patient because the existing legal standard for informed consent is based on that practice. A surgeon simply discloses his/her level of experience with a new procedure, quantified as the total number of prior clinical cases. That number does not give the full story as to how good the team is at the new procedure. The impact of any given number cases on technical proficiency depends on the team and circumstances. Some learn rapidly from their early experience and master the procedure quickly while others struggle early and have a more protracted and dangerous learning curve phase.
The only type of communication that solves this dilemma is brutal transparency. A surgeon who is “brutally transparent” is freed from the bounds of more nuanced doctor patient interaction. There is no guessing by the surgeon about the patient’s information needs. It doesn’t place unrealistic demands on the patient to be assertive enough to ask questions #2 and #3. Instead, the surgeon just goes ahead and sticks the unvarnished truth out there, ignoring that the patient may not to like the answer and refuse consent. This has many downstream benefits. It focuses the surgeon on a renewed sense of accountability. It avoids the corrosive effect of normalized deviance. The whole OR team will let out a sigh of relief because they knew it was not fair to initiate the program with such minimal training in place.
Of course, there are legitimate debates to be had about adding the “brutal” to our efforts to be transparent. Information phrased in a way that is “brutal” can be distracting and runs the risk of being prejudicial. That means it can inflame the mindset of patients and blind them to better alternatives. For example, cardiac surgeons have complained bitterly for years about cardiologists’ affinity for the phrases “splitting open the sternum” or “cracking the chest”. This is their shorthand description to patients on a cath lab table about conventional cardiac surgery. The surgeon’s objection to this colorful language is that it makes patients excessively focus on and worry about the short term morbidity of an open operation. With less inflammatory language, the patient might be more open to understanding that PCI doesn’t always have the same long term benefits of surgery. Prejudicial information can be used to manipulate people into the wrong decisions. Understanding this problem is why there are guidelines from the cardiology societies to have a surgeon consult on patients prior to undergoing multivessel PCI.
In the most famous court case of our lifetimes, Christopher Darden objected to OJ Simpson defense counsel’s use of the n-word when describing actions of the LA Police. He argued that it wasn’t important to the question of Mr Simpson’s guilt or innocence and would prejudice the jury and lead them away from the facts of the case. Johnny Cochrane defended its use by restating the obvious – black people/jurors are intelligent and can handle conflicting information: a horrible crime was committed that deserves justice and some of the police investigating that crime were racists. The judge sided with Mr. Cochrane.
Similarly, arguments against brutal transparency for robotic cardiac surgery are likely to suffer the same fate as the one posed by Mr. Darden. I am defining brutal transparency in this case as the disclosure of the surgeon’s prerequisites and training in a way that is understandable to patients. How are patient interests being advanced by glossing over problems with training? It is a shame that our profession has been infected with the wide array of conflicts of interest that led to this training fiasco.
According to Supreme Court Justice Louis Brandeis: “Sunlight is said to be the best of disinfectants.” He was not talking about the light from a candle, but that derived from the brutal intensity of the sun. In order for disclosure to work, it must be real. The knowledge of the facts must be actually brought home to the patient and be stated in good, large type. While the best answers to questions about clinical care are not always clear cut, putting the patients’ well-being first is the best guide to appropriate ethical behavior.
In the end, the greatest beneficiary of brutal transparency is not patients. This new standard provides the surgeon with a major incentive to never have a conversation about inadequate training. Either way – having the conversation or trying to avoid ever having it – would drive a change in the way surgeons view the importance of their training and the autonomy of their patients. In that sense, the most important rewards of brutal transparency are measured by the renewed integrity of surgeons.
