Since da vinci’s robot was introduced in the 15th century, humans have been fascinated by the topic of robotics and respond with a mix of curiosity and skepticism, as illustrated by Ms Metz’s New York Times article about the use of robotic to aid in surgery. Emotional reactions like this, when kept under control, can be healthy and promote steady improvements in how this technology is used to help patients. When out of control, it can also become pathologic and halt progress. The key to keeping things under control is to honestly assess the strengths and weaknesses of the idea.
Spaceflight has also stirred similar emotions that have gotten out of control at times. NASA had meetings to discuss the Space Shuttle for many years prior to the explosion of the Challenger in 1986. Each meeting had engineers in attendance that knew about the problems with the O-rings but failed to speak up. Every time these meetings avoided the O-ring issue, it had the unintended effect of normalizing this latent hazard and sealing the fate that a rocket would sooner or later come crashing down to earth. The lesson our nascent field of robotic surgery must learn from this tragic case is not just that it is important to speak up about the real problems, but that we must constantly be aware of what can and will happen if we don’t.
The risk of preventable injury to a patient during robotic surgery is much higher than astronauts face during space flight. The actual hazards are almost never the technical issues mentioned in the NY Times article. A time lag between command and execution or the precision of a robotic arm being off a half centimeter are fascinating topics for cocktail parties, but not relevant to patient safety. The problem is far more fundamental and hiding in plain sight: poor communication. Excellent technical skills are necessary but not sufficient for good surgery; there are also a wide array of nontechnical skills involved. Medicine in general and surgery in particular is a team sport. Anyone that has ever been part of a team knows that all its members must be on the same page. In surgery, it is called having a shared mental model. The most important thing a teammate does is communicate effectively. Communication skills are critically important for a successful outcome.
A robot in the operating room changes communication in a dramatic fashion. There are new ways to communicate – the surgeon sits in a corner and is no longer standing at the operative field, which makes implicit communication less useful. There are new things to communicate – small incisions take away the surgeon’s direct vision of the operative site; video cameras and/or echocardiography are needed to explain what is going on. There are new dangers to watch out for– there is a risk for injury during a conversion from robotic to open surgery and new challenges in handling bleeding. The communication skills and mental models of surgeons have been honed for open surgery but not robotics. We demand a myriad of new technical skills to grant credentials for robotic surgery, yet we accept the same old nontechnical skills of open surgery. This false assumption ultimately impacts team resilience by inviting communication breakdowns. That turns a “near-miss” into a bad outcome.
Regardless of how good our technology becomes, we will never prevent all bad surgical outcomes. However, publications inadvertently perpetuate harm when they fail to speak up about real problems. To a news outlet like the New York Times, the nuance of how a team communicates during robotic surgery is not as compelling of a topic as autonomous robots. However, the focus on technical aspects to the detriment of nontechnical makes it seem like the field does not even recognize it has a problem. Atul Gawande improved the safety of open surgery with a low tech solution – checklists. Once robotic surgeons tailor their communication skills to the unique issues they face, they will do the same for robotic surgery.
