Robotic heart surgery programs tend to be promoted and publicized during their initial adoption phase, often times extravagantly. It is important to understand the circumstances surrounding the hype. Hospitals are simultaneously horrified and thrilled by a heart surgeon who wants to adopt a new robotic approach. Their intrigue is derived from the belief that the great promise of the procedure will be realized, shared with the unspoken fear that things will end disastrously. This complex mix of emotions is analogous to what attracts us to watch a high wire act at the circus. However, new robotic cardiac surgery have a risk of programmatic “death” (i.e. abandoning the program after it was started) that is far more common than for acrobats on a high wire. Based on data from a recent national meeting (http://meetings.ismics.org/abstracts/2015/C21.cgi ), only 1 out of 20 programs that have gone to robotics training and attempted to do cardiac cases using the robot have been able to achieve sustainable success in cardiac surgery. There are tremendous clinical, morale and medicolegal risks left in the wake of these failed programs. Since no sensible surgeon or administrator would agree to take on risk needlessly, there must be a reason why so many cardiac surgical programs have been interested in pursuing robotics in the face of this high failure rate. To answer that question, one must appreciate the power of hype.
The basic idea of a robot doing heart surgery has tremendous power because patients want it. Healthcare consumers assume that when they are recommended to undergo surgery, the least possible invasive option is always suggested. However, only a minority of heart surgery programs offer less invasive approaches; most use only standard open methods for every case. While not every case is right for robotic surgery, the patient’s assumption that it will be offered to them when it is appropriate may depend on where they were referred for surgery. If they don’t end up at a program that offers the robotic option, the idea that they could avoid the sternal saw (at another center) might not ever be discussed. Many referring doctors and patients aren’t aware of less invasive options. That leaves patients getting invasive surgery more frequently than would be based on their own preferences and a more transparent system that provided them with all the options.
From the patient’s perspective, information about less invasive heart surgery is highly valued. Correctly or incorrectly, many patients with heart problems think that they won’t tolerate having their sternum sawed open. These desperate patients are looking for any option out. Less invasive heart surgery programs send the message that they understand their patients’ fear and the option of robotic surgery quickly differentiates them from the local competition. From the hospital’s perspective, the ability to be competitive in a high profile service like cardiac surgery yields major contributions to the bottom line. From the general public’s perspective, the idea of involving robotics to make human hearts better is irresistibly fascinating. It taps into our collective imagination of what the future of healthcare is going to be like as robotics and computers continue to improve the way we do things for the better.
Problems often begin when marketing departments at hospitals jump in to take advantage of the public’s fascination. It is their job to promote the robotics program and the hospital’s overall reputation. However, marketing messages can exploit the combined hopes of patients, referring providers, hospital administrators, and the public and lead them toward expectations that are inflated beyond what the surgical team can deliver. Predictable problems occur when there is a gap between excessive expectations and a more grounded reality.
The grounded reality is that there are real clinical benefits. Most importantly, robotics reduces blood loss, infection risk and recovery time after surgery. This has been demonstrated in every field where the robot has been used including in cardiac surgery. These benefits are important. Bleeding, blood transfusions and infections are common early after heart surgery and can trigger subsequent lung and kidney problems and prolonged stays in the intensive care unit. Surgical infections are particularly common in diabetic patients, which represents a growing subset of patients that require heart surgery. Analogously, the desire to avoid a prolonged recovery time after heart surgery is the main issue that has driven the success of catheter based interventions to treat blocked coronary arteries (angioplasty and stenting). Outcomes of cardiac surgery with an open sternal incision are excellent. But bleeding, infection and prolonged recovery times remain the Achilles’ heel of the status quo and further improvements have stalled. Robotics represents a disruptive innovation where major improvements in these areas are possible. This type of breakthrough improvement in outcome should be celebrated.
Another reality is that less invasive surgery is still surgery. Prolonged pain, complications, and death are possible. There are major challenges with getting a smooth functioning robotic heart surgery program off the ground. This early phase, known as the “learning curve”, comes at a politically bad time because it almost always directly coincides with the peak of inflated expectations. As early struggles are encountered, the gap between expectations and the reality of the new program grows. This gap has a way of making reality seem even worse than it really is. Even some of the most committed surgeons and institutions are unable survive this phase. The fear of history repeating yet another failed cardiac surgical robotic program can become paralyzing. Only with the help and advocacy of those highly skilled at organizational dynamics will the robotic team be given the opportunity to persist towards a plateau of productivity where the promise of robotics can ultimately be realized.
There are a lot of roadblocks and challenges that must be overcome to improve a complex and conservative field like heart surgery. Understanding and managing the impact of the hype effect is a very helpful step.