Cardiac Surgery with a Robot: It Benefits Patients, but can Harm Surgeons

Patients, motivated by their fear of large and morbid surgical incisions, view robot heart surgery as an incredibly good idea.  The lay public is now well aware of laparoscopy and how it proved that large incisions aren’t always required for effective surgery.  If a patient can get the same results with a less invasive method, why would they want a more invasive approach?  I have previously outlined the evidence that major complications such as stroke are significantly reduced by robotic CABG.  The logic of both a quicker recovery and less risk of stroke is a “no-brainer” to the elderly, frail population of patients often referred for cardiac surgery.  These facts lead us to an obvious question that inspired this post: why don’t all heart surgeons use robotics for their procedures?

Two decades after the first time coronary artery bypass (CABG) was done using a robot, it is clear that robotics has not been embraced by heart surgeons.  The total number of robotic CABG per year is currently around 2000-2500, which is <1% of open CABG.  Robotics was initially greeted with enthusiasm.  In the early 2000’s, nearly 400 US cardiac surgeons attempted training for robotic CABG.  It was subsequently abandoned and there are now fewer than 20 programs remaining currently active.  In contrast, the open sternotomy method of CABG was the most rapidly adopted surgical innovation in the history of medicine.  Twenty years after the first case in the 1960’s, 500,000 open cases were performed annually at over 1000 programs.

This difference between what patients want (small incisions) and what surgeons are willing to provide (open sternotomy) illustrates how the motivations of these two groups differ.  There is a simple reason why the adoption rate is so low.  Its the same reason physicians are reluctant to adopt any new treatment idea.   Doctors hate to be blamed when a patient has a complication.  Everyone knows and accepts that complications happen after open heart surgery.  But when this happens after the new, robotic approach is used, we tend to blame the surgeon.  “There must have been something that the surgeon did wrong – poor case selection, not enough training, miscommunication with the team, etc.”  When complications happen after the traditional open approach is used, we blame god.  “The patient was given the option that is standard of care: we can’t expect 100% success.”

Getting a team to safely adopt a complex, high risk, novel procedure (with inadequate training and mentoring) is like fighting Mike Tyson.  As Tyson himself said, “Everyone has a plan until they get punched in the mouth.”  Sometimes the robotic team must deviate from their initial plan after they get punched in the mouth by an unexpected event and must save the patient using an emergency “bailout” maneuver.  The most common approach is to abandon the idea of less invasive, remove the robot from the operative field, and convert to a full sternotomy.  This event, abbreviated as a “conversion”, is usually completed efficiently with no added harm to the patient other than a larger incision than they expected.  A small number of these events (around 0.5%) are associated with major complications such as an intraop stroke.  An unforeseen adverse event of this magnitude has intense salience and vividness, to all stakeholders in the program, particularly those on the fence about robotic CABG.

The field of cardiac surgery, perhaps more than any other, overvalues certainty and control.   The most certain way to control that risk of conversion is to start with the sternotomy in the first place.  The risk of an open CABG having to convert is always 0%.  Yet this represents only the illusion of control related to the risk for postop strokes.  These strokes are caused by atheroemboli dislodged from the ascending aorta by the cannulas, cross clamps and other tools only used during open CABG.  Robotic CABG completely avoids this aortic manipulation and is associated with a 3-fold less risk of stroke, even with the risk of conversions included in the analysis.

The stroke advantage of robotic CABG is grossly underappreciated among experts, largely because not all strokes are equal in the eyes of surgeons.  Experts often over-weigh the small risk of stroke caused by an unexpected conversion of a robotic CABG case.  At the same time, they overlook the larger risk caused by open CABG because it is a more routine occurrence.  It is the uncertainty of whether a given robotic case might require a conversion is emotionally distressing for many surgeons.  It can trigger a risk aversion similar to feeling the risks of driving (you are in control) are lower than flying (you lack control).  In both open CABG and driving, the illusion of control is betrayed by a risk for harm that is actually several fold greater than the alternative.

No surgeon will consciously acknowledge that their risk of getting personally blamed for a bad outcome is influencing their opinions of robotic CABG.  Instead, they rationalize an aversion to robotics by saying it is inherently unsafe.  In other words, it has an ever-present danger that overshadows any of its benefits.  This is quite unlike a novel procedure that has the hazards of early adoption, but then improves as the team gains proficiency.  A frontal lobotomy is an example of an inherently unsafe procedure – its risks always exceed benefits.  No skill and/or experience makes a lobotomy safer.  Some procedures that were standard of care in the past, like open cholecystectomy, have become inherently unsafe for many patients relative to the less invasive alternative (now a new standard).

Yet debates about safety can feel like trying to nail jello to the wall.  Safety is defined using a notoriously flexible yardstick that often follows “gut” instincts.  Our gut can lead us astray.  For instance, most people have the gut feeling that traffic intersections with roundabouts are more hazardous than those with stoplights, yet the data consistently shows 75% less traffic injuries with roundabouts.

It is a logical premise that all procedures that are unnecessarily unsafe relative to alternatives will eventually be abandoned. Opponents of robotic CABG often point to the large number of surgeons that abandoned as clear and convincing evidence of its poor safety.  But concluding that a procedure that is abandoned is proof that it is unsafe is merely a reversal of our initial premise.  Reversals like this are a logical fallacy known as affirming the consequent (If A, then B. B is true, therefore A is true).  In addition, it is a conclusion not supported by the facts.  Many surgeons abandoned robotic CABG without having any concerns about its inherent safety.  Oftentimes, they just didn’t think the hassles of robotics where worth the effort.  It risked their reputation with no more reimbursement or prestige.  Instead, the rewards flowed to the outspoken opponents, whose careers continued without having to implement the uncomfortable major change of robotics into their practices.  I also know some that only temporarily suspended their programs.  They straddle the fence in public as a way of hedging their bets, ready to leap down at any moment, restart their robotic program and declare they had foreseen its value all along.  All they are waiting for is an excuse.  These varying opinions illustrate that collective behavior (like abandoning an idea) is driven by a single rule – the benefits of joining the group’s viewpoint exceeds the costs – but rarely by a single motive.

A big factor driving surgeon’s negative view of robotics is that its positive features can be quickly overpowered by isolated negative events.  Its positive aspects are mainly better visualization and dexterity which improves hemostasis and surgical accuracy.  These technical enhancements are experienced in the moment as surgery is performed.  Psychologists have shown that our judgments come from memories and these memories are not usually based on experiences in the moment but rather key salient events that happened.  A bad outcome or near miss during robotic CABG burns a deep impression on surgeons, leading them exaggerate the gravity of these moments.  The promise that robotics will improve outcomes is betrayed by such unexpected events, creating a gap between expectations and reality.

Surgeons that have decided not to offer robotic CABG are not anxious to divulge that it exists at another local center, thus creating a motive to ignore evidence that supports its benefits.   Studies that support less stroke after robotic CABG are retrospective and have not been confirmed in randomized trials.  Waiting for more data is appropriate for some topics, but in this case it is a poorly veiled delay tactic.   The idea that such a “no touch” approach reduces stroke is obvious on the face of it, even to non-surgeons, and this relationship has been proven in other contexts. Concepts which such strong face validity make awkward topics for prospective trials.  Its analogous to a randomized trial to confirm that parachutes prevent death after falling out of an airplane or one to test the validity of global warming before agreeing to any meaningful action.  We improve neither science nor patient care by trying to prove obvious ideas to those highly motivated not to believe.  In cases like these, change is motivated by social pressure and not by more evidence.

It is the unexpected adverse event that opens the door to blame and punishment.  Not all complications that happen after CABG are judged as equally blameworthy.  The founding principle of medicine is “First, do no harm”, which means to avoid errors of commission.  A logical extension of this idea is that we accept errors of omission as far less blameworthy .  For example, patients made “DNR” die due to an act of omission (no further care given).  On the other hand, euthanasia is used in the same type of patient and has the same outcome, but physicians and society view this situation much more negatively because it is a deliberate act of commission.  Similarly, a stroke caused by trying something new (robotic CABG) is an error of commission – this causes regret and is judged as a major loss.  In contrast, open CABG is the standard of care and postop stroke is an expected complication.  Failing to reduce the risk of stroke even further via a novel method like robotic CABG is an error of omission or forgone gain.  Since the techniques used during open CABG fall within professional norms, a stroke in this setting is a blameless error.  In contrast, robotics is a deliberate departure from those norms.

Prioritizing sternotomy over a robotics approach means that 1 unforeseen stroke is being traded for 3 expected strokes.  From the perspective of patients and their families, this is an illogical trade.  A layman sees no moral or logical distinction between these two different types of strokes.  Both are equally devastating, so both generate equal blame from families.  But their opinion has minimal impact because physicians, not patients, are the ones responsible for adjudicating blame.

Physician-experts assign blame after making a series of judgment calls (in other words, its a highly subjective process).  As stated, most adverse events after robotics have the intrinsic negativity of an “error of commission”.  This can turn many important judgment calls against the surgeon.  In the aftermath of an adverse event, old concerns often resurface that robotics is inherently too unsafe for heart surgery. The prior view of a robotic CABG surgeon as a brave innovator changes into someone seen as somewhat reckless. Allegations like this mean that not only the judgment of the robotic surgeon is impugned, but also his/her character.  The surgeon with character flaws starts being second guessed on a host of other issues, like why there was not better a priori planning before initiating the program.   Persistence in the face of the immense challenges of the robotic learning curve was at one time considered laudable but now reinterpreted as evidence of an irresponsible disregard for patient safety.  Since the skills required for robotic CABG are so rare, they start to be viewed suspiciously as idiosyncratic and as evidence that other basic skills must be lacking – like the autistic savant who knows how to calculate square roots in his head but can’t do basic math.

The above constellation of character flaws – reckless, poor planner, irresponsible, rebellious desire to contradict norms, lack of some basic skills – is a literal characterization of the exact phenotype of a person that can’t learn from their mistakes.  Indeed, neuroscience research has demonstrated that the brain of someone with this set of behavior disorders is literally hard-wired to repeat the same mistakes over and over.  It is reasonable to consider protecting patients from surgeons that fail to learn from their mistakes and continue to perform unsafe procedures.  In fact, proposals for even the most lenient environment in healthcare – known as the “blame free culture” – specifically require surgeons to be held accountable when their behavior is deemed to be reckless.

The intrinsic safety of any new procedure and the corresponding safety attitudes of the surgeon performing it is fair game for critique and debate.  Frontal lobotomy was a gruesome surgical procedure common throughout the 1940’s and became even more common after it was awarded the Nobel Prize in 1949.  It only became outlawed after public was made aware of its problems in the novel “One Flew Over a Cuckoo’s Nest” in 1962. Over the past 2 decades, well publicized catastrophes in operating rooms  (e.g. wrong leg amputations) have shocked the lay-public, further removing the veil from the OR and forcing accountability.   Today, we have entered an era where patients no longer blindly accept that everything is being done within hospitals to prevent harm.  In fact, the most recent Gallop Poll shows that patient trust in physicians has recently declined far less than that of nurses, in part because of concerns about safety.

Many cardiac surgeons accuse those that perform robotic CABG as further eroding that trust by trading away the reliability and safety of the open procedure merely for cosmetic benefit.  To them, this procedure is a modern version of the frontal lobotomy: an inherently flawed and unsafe gambit.  They dismiss the idea that training and experience will change things and see the future of this procedure as analogous to a rose bush growing in a desert. It may be possible for some programs to produce a few beautiful results for a time but, sooner or later, the desert always reclaims the rose.

At the same time, any investigation capable of protecting patients would recognize how biases and subjective judgments feed the desire to “crucify” the robotic CABG surgeon.  The desire to blame, shame and punish provides a fantasy of resolution that is seductive and often politically expedient.  Unfortunately, it prevents deeper consideration of more important root causes such as training, teamwork, leadership development and other systems issues.   Once such incorrect judgments are made, all serious inquiry ends and the hospital leadership becomes pressured to respond unwisely, with a common trap of forcing a high quality robotic CABG program to give up too soon.   The underlying motivation for this type of a flawed investigation is to punish the idea of robotic CABG, not just the surgeon, and deliver a clear message: “cease the heresy”.  The punishment is not for violating rules of safety, but as a tactic of stopping debate.

A historical fact worth remembering is that in 2008, experts gave mortgage securities the highest AAA rating right up to the point the market exposed them as worthless, which ultimately caused a global financial meltdown.  This highlights that accurate and unambiguous rating systems are critical to guard against disasters.   But the criteria for judging the quality of robotic CABG programs are also ambiguous, so we substitute the opinion of experts. One thing that real experts know, and that non-experts do not, is that they know less than non-experts think they do.  The public attributes greater authority, precision and lack of bias to the opinion of experts than is warranted.  It is worth remembering that every malpractice case at trial has one expert testifying under oath that malpractice occurred and another swearing that it didn’t.  Opponents of robotics often exploit the subjective nature of “standard of care” as a chance to attack the skills, judgment and character of robotic surgeons.

It makes these attacks less personal to realize that a majority of my cardiac surgical colleagues have not personally weighed the relevant evidence.  Collective judgments about things like the personal character of a surgeon who performs robotic CABG are often started by a few seeds of doubt sewn by a few influential members in the field.  Their opinions rapidly cascade among the profession at large and soon create a collective point of view that is hard to change.  Evidence that contradicts this view – such as zero strokes after my last 500 robotic CABG cases – is ignored to avoid going against a collective momentum. Actions speak louder than words, but in situations like this where information cascades have a major influence, the collective words and actions of the group may not reflect their underlying thoughts.  A debate over a topic as important as the safety and efficacy of robotic CABG and/or the judgment and skill of the surgeon performing it should be resolved by the use of data, logic and reason.  Instead, it is more often resolved by social force and political power.

The end of the journey for robotic CABG surgeons is to arrive where we started and know the place for the first time.  Many of us discovered (the hard way) the critical need for teamwork to improve the safety of robotic CABG and other cases.  During our learning process, the whole hospital has gained a new set of competencies that has pushed it closer to the ideals of a highly reliable organization.  I predict that once these issues are more broadly understood and implemented, the majority of CABG procedures will someday be performed without a morbid sternotomy.  However, the last two decades have shown us that this transformation is not likely to happen smoothly and will require a revolutionary shift in thinking.  According to the philosopher Thomas Kuhn, such paradigm shifts tend to be most dramatic in fields like CT surgery that appear to be stable and mature.  Surgeons afflicted for decades with affluenza have blind spots.  That creates the soil that is fertile for a revolution.  To paraphrase a line of a famous revolutionary – “The arc of the cardiac surgery is long, but bends toward less invasive.”  Our direct line of sight doesn’t provide the complete story of where we are going, but surgeons with vision see robotics as a good bet for the future.

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