Friday, March 7, 2014

Televised live surgery: Would you want to be the patient?

"Defibrillation, defibrillation, where is the defibrillator? We did a mistake while talking," said a cardiologist when a patient went into ventricular fibrillation during a live broadcast of a percutaneous coronary intervention at a meeting in Europe last year.

Before it was recognized by the operators, the complication was identified by members of a panel and an audience who were watching the procedure remotely.

The Medscape article with a link to the video of the procedure is available here.

Live broadcasting of procedures—is it really educational; is it just self-promotion; is it marketing?

Several societies have published guidelines for live broadcasts of operations and procedures, and some papers have discussed the ethics of the practice. I won't get into those areas.

Here are some things to consider.

A few studies have reported that outcomes of live broadcast procedures are equivalent to those found in cases without observers. A paper on live transmitted carotid artery stenting showed that technical success was achieved in 185 (99.5%) of 186 cases with complication rates similar to those in the current literature.

Compared to 847 standard procedures, the outcomes of 39 live broadcast robotic partial nephrectomies were not significantly different. The paper concluded, "Live robotic surgery represents a powerful educational tool which may be used without increasing patient morbidity."

Is it really more powerful than an edited video? Why would that be so?

Reports of mishaps are few and far between. A patient who underwent live video surgery in Japan died two days postoperatively. Like the PCI case above, this came to light in a non-peer-reviewed publication. And as in the PCI, the surgeon was answering questions from the audience while doing the procedure.

Ninety members of the American Association of Genitourinary Surgeons responded to a survey. Most (93%) had performed live surgical broadcasts as visiting professors, and 73% of them rated their anxiety levels as either moderate, high, or very high when doing these procedures. Just over 40% said excessive conversation in the OR was a major distraction. But most telling was that "Only 28.2% of AAGUS members would let a visiting faculty member operate on them or a family member."

Over 270 vascular surgeons replied to a survey about live case demonstrations, and one-third of them felt that patients were exposed to more risk in this setting. More than 70% said they would support the decision of a relative or friend who undergo live demonstration surgery, but only 44% said they would undergo such a procedure themselves.

Another survey included 253 urologists who felt that live case demonstrations were more beneficial than edited videos mostly because of the opportunity to ask questions and to see the entire case. However, only 58% would agree to having a family member or themselves be the subject of a live broadcast procedure.

Survey responses were received from 63% of 856 ophthalmology consultants in the UK. More than two-thirds felt that live broadcast surgery offered no educational advantage over edited videos, 92% said that the surgeon was placed under greater stress, and 83% felt that such surgery was not in the best interest of the patient.

Here's what I think.

If most surgeons would not allow live broadcast surgery on themselves, then why should any patient be subjected to it?

A major complication will inevitably occur during a live broadcast. No matter the reason, it will be blamed on the live video surgery.

Still not convinced? Then take a look at this emphatic opinion piece by Dr. Duke E. Cameron, chief of cardiac surgery at Johns Hopkins.

If a surgeon feels it must be done, then follow the example of Dr. Andrew Wright, a surgeon at the University of Washington. When he does a live demonstration, he focuses on the patient, and one of his partners talks to the audience and answers questions.

ADDENDUM 3/7/14: Five minutes after I posted this, @MarkCheetham tweeted that all upper GI cancer operations have been suspended at a UK hospital due to excess mortality. One case has resulted in a malpractice suit. A patient died of hemorrhage 5 days after discharge. She had undergone a minimally invasive esophageal resection which had been broadcast live to a conference of consultants and trainees. Link here.


Hope said...

I completely agree that live surgical broadcasts are unnecessary and could be potentially harmful. Live broadcasts should be saved for events that have a specific entertainment value, such as music performances and sporting events. I don't think that the educational value of a taped, edited surgery would be any less than that of a live one. In fact, it may be even more helpful if the monotonous parts are edited out and the key portions of the operation are left in.

RuggerMD said...

Yea, total, total, BS and just self ego rubbing for the surgeon. Nobody ever needs to do this.
You can video your operations and then edit and show the video and identify the important parts of the operation.
Every time I see one of these live surgeries at a conference, I just think "idiots".

Skeptical Scalpel said...

Hope and Rugger, thanks for supporting my position.

George Gasman said...

Primum non....

The other question to ask is this: If we are in the art of surgery for the benefit of patients, who is the beneficiary of such a side sho...sorry, such a *demonstration*. Surely, the patient gets care that is no better than s/he would have had the procedure not been televised. Therefore, the benefit accrues to someone else - the team doing the procedure or the team broadcasting/marketing it.

Educational? I didn't learn to intubate, put in central catheters or do epidurals by watching a live broadcast. I had someone standing next to me while I did it.


I need to retire.

Emily said...

Is the patient aware of the live broadcasting of their operation, or is consent automatically covered when the patient signs the 'general consent to photograph' provision that's in every basic hospital consent form. I'm wondering what would happen if the patient refused because I remember you saying on another post that doctors/surgeons don't like their operating room routines disrupted by patient demands

Skeptical Scalpel said...

A reader was unable to post a comment so it was emailed to me. Here it is.

"I agree that ego rubbing and the surgeon's anxiety are problematic, but I'd like to say that live surgery was indeed very educational to me.

My hospital hosted an hernia meeting. When discussing it, TAPP and TEP, said by the ones who do it, were quick and easy and had an excellent recovery. Since the patients were ours, I could see the procedure being done, the real surgical time, the difficulties, and they appeared after in our ambulatory. I always enjoyed seeing people operating, I learned valuable things, others not very useful, and the opportunity to see leaders in my field operating is awesome.
Edited videos are shit. I don't need to see an experienced surgeon doing a laparoscopic anastomosis. I want to see how she deals with bleeding, how to expose the structures and other details that makes the difference.

A 30 minutes video won't show how to do a 9 hours pancreatectomy.
Maybe the videos don't need to be live, but edited videos are bad stuff."

Skeptical Scalpel said...

George, I agree.

Emily, I fairly certain that patients who participate in these live operations give a specific consent that is more than just an standard form with a photography consent buried among the other gibberish.

The comment about the value of seeing the entire case has some validity and yes, heavily edited cases may not be as educational. So instead of broadcasting the cast live, why not just show an unedited video? The surgeon could then narrate and answer questions without trying to do the case at the same time. I don't see why that wouldn't be just as good.

Anonymous said...

I think there is a unique educational value to live demo over video: "Hey, what's that?" "Can you show me how you..." "What's lateral to your field of view right now?"

In the one live demo I attended, we were encouraged to interrupt. We did - and it disrupted flow and distracted the surgeon. He nicked bowel placing a port just to give us another view.

So it's a risk/benefit question, in my view.

Skeptical Scalpel said...

But the patient is the one assuming all the risk and receiving none of the benefit.

Anonymous said...

I sure wouldn't agree to be a live-demoed surgical patient, especially since the procedures with heavy interest would be rare or innovative.

But, I think live-demos are just on the continuum of medical teaching. Wouldn't a lap chole go faster without a second-year resident doing much of it? The process doesn't benefit the individual patient, but it is obviously a societal benefit to train future surgeons.

Of course live video is different, but is it just a matter of degree?

Skeptical Scalpel said...

That's a good point, but I think there's a big difference between letting a resident do a case with close supervision and performing in front of an audience.

Attending surgeons helping residents don't feel the same amount of stress.

artiger said...

I recall on a couple of occasions years ago going to watch some live procedures, both times with private practice surgeons in private hospitals. (I will admit now, without shame, that this was funded by companies that manufacture mesh, as these were laparoscopic hernia procedures.) There were about 6 or 8 of us that were guests, and we saw about 3 or 4 procedures on both occasions. I don't know about the other guests, but I had been performing these procedures for a couple of years, so I knew the techniques, but I found it helpful to watch and converse with surgeons more experienced than me. This is somewhat different than a live televised event for a larger audience, so this is comparing apples and oranges to some degree.

During a TEP repair, I recall asking the surgeon where he found all those skinny older men with simple direct defects, as all of mine seemed to be fat young guys with complex indirect hernias. He gave me a wink, as I don't think the other guys knew what I was driving at. Then, on a different procedure, what had been described as an inguinal mass/hernia turned out to be a lymph node. The surgeon seemed undaunted, and just calmly explained that this was something of a misdiagnosis, and that it could happen to any of us sometime, and gave some good advice on what to look for to make sure we don't miss a hernia somewhere.

I found the whole thing beneficial, and perhaps would try it myself, both as a surgeon or a patient. Perhaps. But I don't perform cutting edge complex procedures, and certainly hope I don't undergo one. I would probably say no that.

Skeptical Scalpel said...

I don't deny that these things have some value. When I learned laparoscopic surgery from the master Eddie Reddick himself, I watched him do 3 or 4 cases in an OR. That's a little different than televising an operation to 500 people which involves cameras, extra people, questions from an audience, etc.

artiger said...

Scalpel, did Reddick provide some music as well?

Skeptical Scalpel said...

He wasn't yet at that phase of his life. We did use YAG lasers on the pigs though. It was good because we realized how useless the laser was.

artiger said...

I feel shortchanged. I "only" got to watch Barry McKernan. I don't know if he could sing but I found him highly entertaining nonetheless.

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