Tuesday, July 28, 2015

Is do-it-yourself surgery the future of medicine?

Once in a while, I read something on the Internet that is so silly, so outrageous that I can't help myself. I must speak up.

Such a situation occurred a few days ago when I came across an article called "DIY [do it yourself] Surgery: The Future of Medicine?" on a website called FastCompany.

An "interaction designer" named Frank Kolkman has created a robotic Open Surgery Machine which he proposes could fill in need when "middle-class" US citizens who have no access to healthcare require surgery.

My favorite line from the article is an explanation of what Mr. Kolkman's robot can do. "It's designed to perform simple surgeries like laparoscopic surgery in which three or more small keyhole incisions are made to allow a surgeon to operate inside a part of the patient's body after inflating it with CO2."

He proposes that "appendectomies, prostate operations, hysterectomies, and also colon and general inspections" could be done.
Like Malcolm Gladwell who not too long ago said, “I honestly think that…the overwhelming majority of college grads, given the opportunity, could be better-than-average cardiac surgeons,” Mr. Kolkman thinks surgery is so simple that anyone could do it.

But now that we're halfway through the story, we learn that despite the presence of photographs giving the appearance of a home operating room [see below], the whole idea is only theoretical.

Why would the robot, which supposedly would be operating inside the abdomen, need a light shining on the outside of the patient?

But wait, there’s more. "These procedures are already often performed with the assistance of robotic surgery systems; the DIY Surgery Robot would just take those doctors out of the equation."

We have a long way to go before robots will be able to operate on their own.

Performing surgery is a lot different than assembling an automobile, something that robots are good at. The problem is all appendectomies are not the same. Some are easy, and others take a tremendous amount of effort, skill, and judgment to even find the appendix, let alone remove it. Colon resections? Not going to happen with a robot operating alone.

Here are some other questions that the inventor of the do-it-yourself robotic surgery machine has failed to consider.

Is the robot going to make the correct diagnosis? If so, how?

Laparoscopic surgery requires general anesthesia. Who is going to anesthetize the patient? Yes, there is a so-called robotic anesthesia machine. But it has only been used for administering medications and cannot deal with any sort of emergency such as an intravenous catheter falling out or a patient requiring a tube to be placed in his airway. Humans must still attend the patient.

How much would this DIY robot surgeon cost? If the middle-class American can’t afford health insurance, how is she going to afford a robot surgeon that she may never use. What about the cost of the instruments? Who is going to sterilize them and hand them to the robot? Where is the patient going to recover from the anesthetic? What happens if the robot screws up? Maybe the robot can drive the patient to a hospital.

Just like robots operating in space, the DIY robot surgeon is not yet ready for prime time.

PS: I almost forgot; appendectomies are obsolete. Appendicitis should be treated with antibiotics. Maybe the robot can at least start your IV.


artiger said...

Take a look at the device's home page, with particular notice to the disclaimers:


Does anyone else note the irony of the name of the product, "Open Surgery"?

After looking at the link to the article, I'd have to say this is a bit of journalistic irresponsibility as much as anything else. It's kind of like me thinking a trip to Saturn is just a matter of putting on a spacesuit and climbing on board a rocket.

Anonymous said...

What do you expect nowadays? Money money anything for money.

Skeptical Scalpel said...

Antigen, Mr. Kolkman (autocorrect changed it to "kook man") lives in a fantasy world. It must be nice. I wonder how he earns a living.

Anon, I don't understand your comment. Money for whom?

Oldfoolrn said...

I had a personal experience with do it yourself surgery involving a large sebaceous cyst on my chest wall. After a little Lidocaine, I incised it with a #11 blade and expressed the contents. I did not realize the cyst had stretched the skin to such a degree and I was left with a sagging mess. The neurosurgeon I worked with learned of my plight and skillfully removed the extra skin. I love telling the story of how an internationally known neurosurgeon rescued me from such dumb self-surgery. It doesn't work well even for minor problems. Take my word for it!

Skeptical Scalpel said...

It all looks easy until someone loses an eye.

Les said...

To be fair the artist calls it a "thought experiment" the "raises questions about the social value of health care by showing an alternative approach". I think the article says more about the state of fine arts education in Europe than it does about the future or non future of autonomous robotic surgery since he is a graduate of Londons Royal College of Art. Have you seen some of the crap called 'art' coming out of Europe, or the US, lately? One art exhibit had to be cancelled when the cleaning staff mistook it for a pile of trash.


That art was supposed to make you think about the environment. The surgery 'art' is supposed to make you think about the cost of health care or something or other. This surgery project is simply more of the same stuff. Meanwhile a museum curator will purchase this 'profound' pile of junk for display and everyone who views it will feel a bit confused when they don't 'get it'. I hate art that has to be explained.

Skeptical Scalpel said...

Les, thanks for commenting. You are probably right that it was art and meant to get people to think about healthcare cost etc. The problem is that some readers of that article may take it seriously.

For example, I tweeted this yesterday "Here's a device you can use at home to diagnose & operate on yourself. http://prometheus.wikia.com/wiki/MedPod" and someone retweeted it with this comment "I'm amazed we haven't seen any Darwin Awards result from this little gem...."

If you bother to read the link, it says "FDA Approves MedPod for At-Home Use, since FDA approval (June 30, 2070), one dozen have been produced. MedPod 720i Patented, Weyland Industries earns patent (September 2, 2061)." It's science fiction.

Les said...

I did read the link but missed that part. Interesting. My eyes glazed over as soon as I read he was an art student. MedPods will probably be necessary when everyone is a cyborg.

Skeptical Scalpel said...

Then we will have cyborgs bitching that MedPods are insensitive to patients' needs and feelings.

A. Banterings said...

Then we will have cyborgs bitching that MedPods are insensitive to patients' needs and feelings....

That will be progress. The robot surgeon will have the same sensitivity that the human surgeon displays...

Now to discount this is foolish. Look at how science fiction has driven technology today: The Dick Tracey watch...Apple Watch.

Remember the Star Trek communicator? How about the Startak cell phone? Our smart phones are very close to the Star Trek tricorder.

Who would have believed in cochlear implants, growing organs in a lab, or stem cells 50 years ago?

Combine IBM's Watson with the da Vinci Xi (for robot-assisted surgery) and you have a med pod.

"We are the music makers,
And we are the dreamers of dreams" (Arthur O'Shaughnessy)

Skeptical Scalpel said...

I will ignore your insult to today's surgeons.

You said the magic word robot-ASSISTED surgery. It's nowhere near being able to operate by itself. And I doubt it will be able to by 2070. In fact, maybe never.

A. Banterings said...

YOU made the first insult to patients by parodying "patients' needs and feelings" in your cyborg/med pod example. Do patients' needs and feelings NOT matter to you?

This comment (whether you intended it to or not) comes off as dismissing the patient's humanity and dignity as them being "whiney."

Don't deny this is the way patients are treated systematically. Read Lucian Leape's most recent papers on the six categories of disrespect and how it impacts medical errors published in July 2015 in the journal Academic Medicine.

We already have cyborgs: the Retina Implant AG (Germany) microchip that help the blind see, cochlear implants, artificial hearts, artificial heart valves, artificial joints (knees), prosthesis that react to nerve impulses, etc.

Google has a car that drives itself. Self driving cars ARE legal in California. MIT has already created a self-aware computer. Combine the da Vinci Xi, Google car, MIT self-aware computer, and the computing power of Watson and you have a med pod.

The mentioning of the MIT computer is to acknowledge the "art" of surgery where Watson and the Google car are the science. That self awareness is what will help the med pod make a person beautiful again after an accident.

That part may be further off, but routine surgeries are going to be handled one day by med pods.

Skeptical Scalpel said...

Perhaps a sense of humor will be missing in the future too.

Your reference to Leape's papers led me astray until I found them in the July *2012* issue. Interesting.

I assume you are a doctor but you must not be a surgeon because if you are, you would realize that the da Vinci robot is merely a tool used by a human surgeon. It cannot do anything (except occasionally run amok) by itself.

Self-aware computer or not, it will be quite a while before a robot will be able to operate on a human without another human being involved. There are also the issues of anesthesia and recovery for now and the foreseeable future.

Here are just a few examples of recent computer malfunctions that might cause problems if they occurred during an autonomous robotic operation.

Hackers remotely control/disable a car through its entertainment system. http://www.wired.com/2015/07/hackers-remotely-kill-jeep-highway/

Acuras recalled because they brake for imaginary obstacles. http://consumerist.com/2015/06/11/acuras-recalled-because-they-auto-brake-for-imaginary-obstacles/

A single router goes down and cripples United Airlines entire system. http://www.wsj.com/articles/united-flights-grounded-due-to-computer-issue-1436361911

Computer glitch halts trading on the NY Stock Exchange. http://www.ibtimes.com/wall-street-journal-homepage-wsjcom-down-nyse-stops-trading-computer-glitch-1999756

A. Banterings said...


If your comment was meant in jest, then I apologize. To me I find it in poor taste. The humor that was once acceptable in the operating theater has come under scrutiny because of abuses and because it is wrong.

Look at how African-Americans were portray in film in the 1930s; acceptable at the time, racist today. The incident with Dr. Tiffany Ingham (http://6abc.com/health/listen-patient-records-doctors-mocking-him-during-surgery/802568/) cannot be dismissed as OR humor.

At the extreme is Dr. Twana Sparks (http://www.outpatientsurgery.net/resources/forms/2010/pdf/OutpatientSurgeryMagazine_1001_ent.pdf) whose sexual abuse of patients was laughed off as OR humor for over 10 years.

You examples of software glitches does not prevent the things from existing, they only interfere with the operation. in the same respect there have been surgeons who have had really bad days, get the flu, have food poisoning, etc., and postpone surgeries because they fear for patient safety.

Is that not a "human glitch?"

I am aware of these problems with technology including the da Vinci Xi problems of causing of iatrogenic trauma by the cauteratory tool.

My point is that we have the components that can do surgery if we combine them. NO OFFENSE to you, but you do not have the best grasp on technology available today. In your "ABOUT ME" section you admit that you are unaware of the how advanced web bots are.

Look at telephone systems of large corporations that understand voice commands. We are there with the technology. My Arthur O'Shaughnessy reference was used in the original "Willy Wonka and the Chocolate Factory" movie to explain the amazing things thought not to exist.

That has been the explanation of so much technological advancement. What if I told you time travel is possible and we have already achieved it in the 1970s?

Here is proof from the series Nova (PBS): https://www.youtube.com/watch?v=gdRmCqylsME

This is a good explanation of the physics behind it (Derivation of Time Dilation): https://www.youtube.com/watch?v=p2nwdS3ia24

I can also see you not grasping the technology available today from your arguments against med pods happening. The strongest argument would be plastic surgery. The surgeon is an artist, restoring beauty (a very subjective and abstract concept) to an injured human.

The best PSs start with all the measurements and mark the landscape, but it is in the middle of the procedure that they may deviate the symmetry of the tissue to itself, to create the illusion of symmetry of the whole body (think breast reconstruction).

That is the argument against autonomous robotic surgery (which my MIT argument dispenses with).

Much of surgery now is delivered by machines, what we only need to do is have an algorithm to determine the delivery. But is that not what protocols, procedures, and checklists are? All we are doing is automating them.

The concept of the med pod is best seen in the 2012 movie Prometheus (http://www.imdb.com/title/tt1446714/). In the movie, Elizabeth Shaw uses it to remove the alien from her abdominal area. First the med pod is only programmed for male procedures and there is no procedure for removing aliens.

This demonstrates limitations and solutions that med pods will face early on. The limitations will be on inputting data (basically of all the things that can go wrong with a procedure) and making the algorithm intuitive. These are the same problems that self-driving cars face. The vastness of the topography of the continental United States is comparable the the human body.

Getting a car to self navigate that, react to the unexpected (kids running out in the street, road work, weather events, etc.) would be on par with getting a robot to navigate the human body.

Finally, if it is not until 2070 that we have med pods, the technology by then may allow us to live to 200 years old...

artiger said...

Banterings, when you have a gallbladder attack or acute appendicitis, please don't bother with us. Please feel free to get your machine to take care of it. Not sure? Consult your machine.

Please don't pollute this site.

A. Banterings said...

Why the hostility?

I am simply pointing out that the technology is available now. My reference to the O’Shaughnessy quote deals with open minds; the possibilities of what could be, different views, etc.

If you look at what I have said, I have spoken nothing but truth. If there was a misunderstanding, I apologized for it (more than most do).

Comments such as these lead me down a road that I have been trying to avoid; the perpetuation of the stereotype…

So why the hostility?

Skeptical Scalpel said...

The technology is decidedly not available now. Maybe it potentially is, but a self-operating robot? I'm afraid not. You never addressed the questions I posed near the end of my post about diagnosis, anesthesia, cost, instruments, recovery, etc. Sorry, none of this is ready for do-it-yourself use now.

If you think it is, please give me a reference.

artiger said...

Banterings, sorry if that came off as hostile. Please see Scalpel's post above.

frankbill said...

A. Banterings you said...

YOU made the first insult to patients by parodying "patients' needs and feelings" in your cyborg/med pod example. Do patients' needs and feelings NOT matter to you?

I I have read many posting by both Skeptical Scalpel and artiger. If there were more Dr like them our heath care system would be a lot better off.

Self driving cars ARE legal in California As long is a human is sitting in the drivers seat. Also while so far no accidents have been caused by the self driving cars quite a few have been involved in accidents.

Anonymous said...

I have to echo frankbill. I have typed to Skep off the list and to Artiger on. I may disagree with them from time to time, but I believe from listening to them that we would probably be a lot better off in many ways if they were in the drivers' seat.

I've had a surgeon (or two) not do me right. I know what kind of "humans" they are. SS and Artiger aren't that way.

A. Banterings said...

...and we have auto pilots in planes. Yes, humans are sitting there too.

I also did not disparage Skep or artiger, see artiger's post above.


No problem.


As to your final question; This is actually 2 questions. First is the possibility of self operating robots. The second is if the (above) average person will have their own. I believe the first will be research institutions, big hospitals, military, etc.

I would imagine the first (widely available) med pods will be at the Walgreen's, CVS, etc. clinics. Those and the first home units will handle basics like foreign body removals, suturing, etc. Think similar to laser hair removal technology.

You will probably see the neat ones being hospital algorithms "hacked" for home use so the hacker can give his GF a breast augmentation.

As for the instruments, I have (for personal use) a complete surplus field surgical kit. I do keep a bottle of Prolystica for sterilization of instruments.

I have also seen some impressive personal surgical suites. Of course they are just nostalgic collectors items...

I can go in to any farm supply store and buy most of the basic surgical supplies, couple that with online stores I can furnish a complete surgery center.

The diagnosis will either be self diagnosed or via telemedicine. I see so many companies pushing telemed as ways for companies to keep their health insurance utilization lower. These companies even promise that the the telemed will include prescriptions.

I know that state law for narcotics (one time, not for chronic) require Hx, BP, heart, lung exam (accomplished by a fitbit or similar), but I still question if what the customer expects is what will be delivered? How can a Texas physician prescribe to someone in Boston?

I digress. The other possibility is the patient will get a hands on diagnosis then go home and fix it himself.

There is also a fundamental difference in our thought processes where I don't see limitations.

frankbill said...

The reference to telemed reminds me that on other sites I have heard Dr say that they can not hear all the heart sounds. Seems something gets lost when the heart sound is amplified.

Without proper training one can not self DX. Even Watson is only as good is it is programed. Since many medical conditions have like SX even the best Dr have problems with DX.

Some lab test are affected by what you eat or drink as well as meds you may be taking.

A. Banterings said...


When you say "when the heart sound is amplified," do you mean mechanical amplification (like the diaphragm of a stethoscope), electronic amplification (a "digital stethoscope"), or amplification from the bell of a stethoscope (which is more considered isolation than amplification)?

How are these sounds heard in the first place to know that they are lost when amplified? Perhaps they are referring to about silent atrial fibrillation?

Also note there are FDA approved smartphone apps/devices (such as the AliveCor case and the CardioDefender) that allow a ECG without a hospital/outpatient visit. (See: http://www.fastcoexist.com/1678837/coming-soon-a-hospital-quality-ekg-on-your-smartphone)

You further say, "Without proper training one can not self DX. Even Watson is only as good is it is programed." Exactly the same can be said of physicians.

You stated, "even the best Dr have problems with DX." That does NOT mean that they always get Dx right either. Read these 2013/2014 news stories that link to publish studies that support my assertion of physician misdiagnosis:



Physicians already use Google, "Computer-Assisted Diagnosis Tools" and these tools are already built in to many of the EMR programs. This healthcare system ordered tests before patients were examined based on age, gender, and other demographics: ( See: http://www.healthinsurance.org/blog/2013/06/13/medicare-fraud-and-for-profit-hospitals/ )

Self diagnosing is the wave of the future. (See this: http://www.dailymail.co.uk/health/article-3122724/Phone-app-save-life-Smartphone-gadget-help-patients-self-diagnose-heart-condition-seconds.html)

Many patients, especially those with chronic conditions are better than most physicians at diagnosing their conditions, related events (flare ups), and knowing when something is not related.

There is also a fallacy in the thought that only a physician can diagnose. More and more, other providers are being allowed to diagnose and treat, like pharmacists: (see http://www.cnn.com/2015/07/14/health/pharmacist-prescribe-hormonal-contraceptives/). If physicians can learn to do it, so can (almost) anyone (maybe not as good as a physician or for as many different conditions).

Furthermore self-Dx and self-Tx are inline with the ethical concepts of patient autonomy and the human right of self determination.

artiger said...

I could probably learn to fly a plane. Time, expense, and credentials prevent me from doing so (legally). Treating patients comes with similar "barriers".

I don't know what kind of patient population you are routinely exposed to, but it must be a lot different from mine. The majority of my patients cannot even name their medications, much less the indications for taking them. I'm not talking about a one-time antibiotic, I mean the medications that they take on a DAILY basis.

Look, I'm a big proponent of autonomy, not just with end of life care but also with current day-to-day decisions. But autonomy without understanding is dangerous.

Les said...

I made ONE comment about cyborgs....

A. Banterings said...

But autonomy without understanding is dangerous.

Those are the arguments of Stalin, Lenin, Mao, etc. Nanny government.

Your patients may not know their medications, but that does NOT take away their autonomy...

You may need a license for a plane, but one is NOT needed for an ultralight.

--"The Federal Aviation Regulations (FAR) 14 CFR, Part 103

Skeptical Scalpel said...

Most of my patients didn't know their meds either. The Internet makes me laugh sometimes because everyone on it thinks it's the real world. It's not. This reminded me of a post I wrote last year on the topic, "Ultrasound selfies? How surveys can mislead." http://skepticalscalpel.blogspot.com/2014/07/ultrasound-selfies-how-surveys-can.html

Les, thanks a lot. :-)

A. Banterings said...

What about the patients that do know their meds? What about the patients who are comfortable doing that? I know how to replace the timing belt on my car (after years of SCCA & EMARA racing), but I choose to take it to a mechanic to have that work done.

This is not a mandate, it WILL BE an option. Perhaps the bigger question here is (from your "Ultrasound Selfie" post) WHY one of the results from the Intel survey was "53% said they would trust a test they personally administered as much or more than if that same test was performed by a doctor?"

Why is there such a resistance to some people taking control of their own health?

Perhaps the answer has to do with how satisfied people are with how they are treated during their healthcare experience. Perhaps the attitude expressed here about patients is the same attitude causes harm and suffering:

But now, reducing patient suffering — the kind caused not by disease but by medical care itself — has become a medical goal…

Or loss of privacy...

"These are harms," Dr. Sands said. "They elicit suffering. They can be long lasting, and they currently are largely unquantified, uncounted, unrecorded." (Source: NY Times, Doctors Strive to Do Less Harm by Inattentive Care

Link: http://www.nytimes.com/2015/02/18/health/doctors-strive-to-do-less-harm-by-inattentive-care.html?hp&action=click&pgtype=Homepage&module=photo-spot-region&region=top-news&WT.nav=top-news )

So the thought that the patient does more harm self-Dx and self-Tx may NOT be true although there is no study to compare the two. You can NOT say that Dx and Tx by a physician is without harm either.

Here is a great article on ProPublica, "When Harm in the Hospital Follows You Home." (Link: http://www.propublica.org/article/when-harm-in-the-hospital-follows-you-home)

Just search the NIH's PubMed for "iatrogenic trauma." Every system and every body part has the potential to sustain this trauma. The most common being infection, vascular, urinary, renal, and thorax. Here are just 2 excellent examples:

Marshall JC. Critical illness is an iatrogenic disorder. Crit Care Med. 2010 Oct;38(10 Suppl):S582-9. PubMed PMID:
21164401. http://www.ncbi.nlm.nih.gov/pubmed/21164401

Forgey M, Bursch B. Assessment and management of pediatric iatrogenic medical trauma. Curr Psychiatry Rep. 2013 Feb;15(2):340. PubMed PMID: 23307562. http://www.ncbi.nlm.nih.gov/pubmed/23307562

Here is another way patients are treated: "The dreaded hospital gown, described as health care's prison jumpsuit, often imposed on patients needlessly: study" (Link: http://news.nationalpost.com/health/the-dreaded-hospital-gown-described-as-health-cares-prison-jumpsuit-often-imposed-on-patients-needlessly-study)

Ask any nurse or healthcare professional: one of the most dangerous places for your health is the hospital. Read more at : http://www.beliefnet.com/Wellness/Health/galleries/Reasons-to-Stay-Out-of-the-Hospital.aspx

I argue do-it-yourself surgery IS a way to stay out of the hospital and it is no surprise why patients would rather trust their care to themselves.

Please note that I am NOT saying self care is better, but in lack of a study it MIGHT be. This also depends on the procedure, the technology, and the patient. There are obvious risks of iatrogenic trauma.

Skeptical Scalpel said...

Dear A. Banterings,

My post was only 560 words. Your comments run to over 2000 words at this point. You have a lot to say, much of it thought-provoking. I think it's time you set up your own blog.

My blog is hosted by Blogger, a branch of Google. It's free and very easy to use. There are other platforms such as Wordpress.

Let me know when and if you do so.



frankbill said...

He all ready has a blog.
If you click on A. Banterings name it will take you to his information and clicking on Banterings of a Mad Man brings you to his blog

A. Banterings said...


Exactly what is your point?

Skeptical Scalpel said...

A., I think Frankbill was simply telling me you already had a blog. Why the hostility?

artiger said...

Banterings, you don't need a license for an ultralight, and you don't need a license or training to buy an aspirin. You do need it to prescribe hydrocodone.

You can call it nanny government if you like, but that's hyperbole. Come down here and try to take care of people who can't even read the words we've typed here. I let them make all the decisions they like, but I'm not going to enable people to do harm to themselves (e.g., giving an antibiotic to someone who has a viral infection, even though they really think they should have it). You have no idea how many people I've talked out of having feeding tubes placed in their terminal loved ones ("We can't let Mama starve!" [even though she has metastatic cancer from head to toe]). And on and on.

Certainly, just about any treatment carries a risk of iatrogenic injury. Not treating a lot of diseases also carries risks too.

I'm not sure what your hang up is about hospital gowns. Our patients wear their own pj's or whatever. Unless they don't have any clothes of their own. Then we put a gown on them.

I agree that hospitals are to be avoided unless you are truly ill.

A. Banterings said...


no hostility, against my beliefs of serenity...


i guess you are right about the nanny government thing. especially when physicians can not properly keep records or accurately bill. i can see why then you support ehr....

note: before anyone tries to crucify me for my sarcasm, i am just making a point with the example that i was given. i hope artiger sees how his view applies to him as well.

i believe that we need some regulation, but as a society we have too much regulation.

i never questioned artiger's (or anyone here) ability or compassion. i am sure that you have helped many. i agree with you about end of life choices as well. there was a very good article written in the wsj (i believe) about physicians' choices at end of life.

hydrocodone can be purchased online or (at least use to be) otc in mexico.

"treating a lot of diseases also carries risks too"

is this not the (new) evidence based way of dealing with conditions that have been over-medicalized (wait-and-see)? the implication has been that do-it-yourself is somehow dangerous and the traditional medical response is not (i.e. iatrogenic injury ignored).

i am simply taking in to account all potential risks and benefits.

my whole point has been:

1.) our technology is there, although in its early stages possibly not refined.
2.) technology will refine, become cheaper, safer, easier, and more commonplace. read the history of cell phones (https://en.wikipedia.org/wiki/History_of_mobile_phones)
3.) there are reasons that people would prefer to do things themselves; quality of work, poor treatment/customer service are the predominant reason, not saving money
4.) i explore that perhaps the resistance to the idea MAY be linked to #3. an overly simplified metaphor is teachers' unions opposing home schooling because parents are not capable of educating their children.

as to the gown thing, that is a whole different issue that i am not going in to here... i congratulate your facility for coming out of the dark ages

artiger said...

Banterings, I don't recall saying anything about supporting EHR. I certainly don't like the idea of using it as a billing tool (although I do like being able to access records from outside the hospital).

"hydrocodone can be purchased online or (at least use to be) otc in mexico."...Not a good comparison.

What I said was "NOT treating a lot of diseases also carries risks too." Your argument for something like prostate cancer certainly has merit. Appendicitis, a leaking aneurysm, a heart attack, I'm not so sure. The risks of iatrogenic injury are outweighed by the risks of do it yourself, or wait and see. Unless you consider death or permanent disability to be positive outcomes. Evidence based medicine is not the same thing as wait and see in every disease state.

Someday, self treatment or medical robots or whatever will likely be possible, even the norm. We're not even close to that today, not from the technologic nor societal standpoints.

My hospital is not the only one that lets people wear their own garments. It's really not that unusual these days.

A. Banterings said...


my point to "you supporting ehr" is that almost all physicians say that government should not dictate how they take notes, bill, run their practice, etc. i simply used what you thought to be a "slam dunk argument" to illustrate a "point of view," of government regulation in an example that you surely cannot support.

i created a situation where my argument wins either way...

appendicitis - antibiotics... then wait and see?

"Unless you consider death or permanent disability to be positive outcomes."

guess what? everyone of your patients will die at least once. it is just a matter of when and how we choose that makes the difference. when i go, i will do it on my terms, with dignity, and make it look good.

"Evidence based medicine is not the same thing as wait and see in every disease state. "

when we finally start practicing evidence-based medicine. much of what we have today is ritual. how many guidelines say:

"...despite the lack of evidence, [insert name of organization here] recommends that patients receive [insert ritualistic medical procedure here]..."

i call it voodoo medicine. before i get blasted for this, let me back it with a 2013 nejm reference: http://www.jwatch.org/na32275/2013/09/26/clinical-practice-guidelines-require-scrutiny-quality

we may not be to the point that the salon down the street tanning bed are replaced with med pods, but we certainly have the technology to begin creating the first (rudimentary) med pods; the ones that do suturing.

right now watson plays the same role as any other physician, he is a member of a team. http://www.kevinmd.com/blog/2013/03/ibms-watson-starts-medical-career.html

"In Malcolm Gladwell’s newest work David and Goliath, he suggests that when we fail to recognize both the strengths and weaknesses of different alternatives, we risk not seeing the best solutions. Gladwell argues that we tend to overvalue one particular trait, such as Goliath’s size, while failing to recognize a seemingly less powerful skill, like David’s slingshot ability. The important thing is that each holds a tactical advantage, depending on the conditions of battle."

source: http://www.kevinmd.com/blog/2013/11/watson-siri-david-goliath-health-care-delivery.html

"...wear their own garments. It's really not that unusual these days."

...thank you satisfaction surveys.

frankbill said...

Technology can be a good thing as long as we keep in mind in can become useless if we loose power. In the past few years storms have left thousands without power for two weeks or more. Many had no heat and no way to cook meals to say nothing about cell phone service.

A. Banterings said...


NOT ME! I have a portable generator; do-it-yourself power generation if you will. Yes, I am no electrical engineer and power generation is state and federally regulated, but when storms came through a few years ago and my neighbors were without power for 2 days, life went on as normal.

A bit of sarcasm, but just another illustration of how DYI technology gets in the hands of the common person.

What you also pointed out is the whole basis of Malcolm Gladwell’s book; we have all these great technological advances that improve life, yet they are dependent on electricity. Take away the electricity and we might as well be living in the Bronze Age.

The deeper issue here is the American sense of self-reliance has been undermined by the welfare state. Why do anything when government will provide someone to do it for you?

I remember the cold war survivalist culture of the 1980s and many having machines that produced or a stock of "colloidal silver" (not to be confused with "silver salts"). Colloidal silver is (thought) to be just as good as (if not better than) antibiotics. (I do not want to have this debate either...)

This same self reliance has historically been seen in farmers and in groups like the Amish. One of the last bastions of self reliance is in The Republic of Conch (A.K.A. Key West). See: http://www.conchrepublic.com/history.htm

When we had the gulf oil spill and all the coastal states were crying for help from FEMA, citizens of The Republic of Conch took it upon themselves to be prepared if the oil washed up on their shores. Instead of waiting for FEMA, the municipal government along with private citizens prepared an emergency plan and trained for the event.

All was funded by private and municipal funds. They even began to move coral gardens and had a plan to evacuate remaining coral gardens. See the Time Magazine article: http://content.time.com/time/nation/article/0,8599,1996441,00.html

artiger said...


"i created a situation where my argument wins either way..."

Wow, must be nice to not only be a player in the game, but also to be a referee.

I do support EHR, at least the concept of having a record that is legible and accessible. I do not support the implementation of it such as it has occurred.

For appendicitis, you can treat it with antibiotics and be successful...about two thirds of the time. You can treat it surgically and be successful...about all of the time. You think there aren't complications with treating with antibiotics? Besides that, waiting with something like that can lead to a more difficult operation. Scalpel has blogged about the studies on this area several times, correctly pointing out that the studies are flawed. Still, if it makes you feel better, I do mention this option with all the relevant information to every patient with appendicitis that I see, prior to operating. So far, everyone has chosen surgery.

I agree, our mortality rate overall is 100%. So, are we to abandon health care?

This one, though, really piqued my interest..."right now watson plays the same role as any other physician, he is a member of a team."

Watson might be able to suture the cheek of the 8 year old who got hit with a golf club, if not now, then someday...but can Watson make the child laugh while painful lidocaine is being injected into his wound, or put him at ease by relaying a story of his own episode of being sutured after being hit above the eye with a golf club at a similar age? Watson can explain the indications for a colonoscopy as well as the risks and the instructions for bowel preparation...but can Watson tell you what it's like to go through a bowel prep, or to actually have a colonoscopy? Watson can find a breast lump, maybe even biopsy it (now or someday)...but can Watson sit down and hold your hand as he tells you that you have breast cancer, bring you tissues as you sob, tell you that you are not alone and that you will be OK, and that we'll get through this together? Will Watson sit down and talk to your daughter in California for 30 minutes and explain everything you've already discussed in the office visit the previous day?

A lot of what we do in health care goes beyond diagnosis and treatment. You're missing the human side of it. Sometimes, people come to us without actual discernible pathology...yet they are healed with a human ear, a human voice, or a human touch. I don't know how many times I've had a patient complain about seeing another doctor, saying "he never even touched me". I wonder if cold metal would be better than human epidermis. You tell me.

A. Banterings said...


"Wow, must be nice to not only be a player in the game, but also to be a referee. "

That is what you did with the "hydrocodone" argument. How could I argue against regulating hydrocodone, so hence my "nanny government" was discredited.

I took your argument and did the same thing that you did, so either you support this disastrous implementation of EHR or admit you were wrong.

For appendicitis, I merely pointed out that there were less invasive options.

"I agree, our mortality rate overall is 100%. So, are we to abandon health care?"

But quality of life is not only for end of life.

Watson is the extreme representation of the science of medicine, I realize the human side. Watson is already working as part of a healthcare team treating patients.

Compare Watson to the fictional physician House M.D. He may be human, but is more like Watson than Rex Morgan. Human touch is the art. Believe me, I know about the power of the compassionate human touch.

One of the best examples was told by a doctor that treats HIV positive patients. One patient commented that he appreciates her examining him without gloves [where fluids are not involved] because that is one of the few times that he gets to experience the touch of another human being.

"I agree, our mortality rate overall is 100%. So, are we to abandon health care? "

No, but this takes away that power that many assume healthcare has over patients; their lives. Beauchamp and Childress incorrectly refer to this as "choosing health." This has led to the over-medicalization of life.

The above statement puts quality of life on par (if not above) length of (extending) life.

I realize and accept all those things that you mention. I also do NOT reject the feasibility of med pods or DYI surgery.

"I wonder if cold metal would be better than human epidermis."

I prefer the human touch over both cold metal and the human epidermis.

frankbill said...

How would one DYI open heart surgery?

Skeptical Scalpel said...

As I said in my post, Malcolm Gladwell thinks any college graduate could be a cardiac surgeon. The omnipotent robot should be able to put the patient on bypass and perform the surgery with ease. If blood is needed to prime the heart-lung machine, the robot could make some in the patient's kitchen.

The medical pod would be sufficient for recovery even if the patient required intensive care and mechanical ventilation for a few days. If a robot can do all of that, surely it could wipe the patient's butt too.

A. Banterings said...


Your statement "As I said in my post, Malcolm Gladwell thinks any college graduate could be a cardiac surgeon" is very telling. Theoretically Gladwell is correct that any could be a cardiac surgeon, although not necessarily a GOOD surgeon.

I am sure that you heard the joke, "What do you call the person who graduates last in their class from med school?"


Your umbrage is with your job being replaced by a robot. The feeling is that due to the sacrifice, skill, education, etc. your job should can not be replaced by robots. That was once thought of people who built cars.

There is a big difference between a hand-assembled Bentley coupe and a mass-produced Toyota, but both get you from point A to point B.

If you think about it logically, humans are just organic robots/computers. Neurons are just organic microchips. Granted that human learning is more efficient and intuitive, but eventually we will have programmed in every possibility or what to do if the unknown arises.

Just like with the human surgeon, there will be a fail safe if the unknown/unforeseen occurs. The body is basically a map with each having variations, again easily programmed.

As for the "human touch," we may not have that until robots/computers become self aware. We, as a race are not ready to be creators of a new life form. We will be like the 16 yr old mother with our self aware children.

The biggest problem will be us seeing them as possessions and not as sentient beings. Some of the best books/films that tackle this issue are:

- The Alien movies
- I, Robot (Isaac Asimov)
- A.I. Artificial Intelligence (Steven Spielberg)
- Bicentennial Man (Robin Williams)

Here is an good MIT article: The SElf-awarE Computing (SEEC) Model (Link: http://groups.csail.mit.edu/carbon/?page_id=475)

At the point that they become self aware, then they will be able to show compassion and have the "touch." The rate technology is progressing, I believe that I will see it my lifetime.

Of course, shortly after that it will be "Merry Christmas from Chiron Beta Prime."

Link: https://www.youtube.com/watch?v=B3DyxaCYlfg

artiger said...

Banterings, obviously we see things very differently.

A. Banterings said...


That also gives me a segue to my next thought, let's see if you agree with this:

One of the goals of EHR is to create a library of evidence based guidelines. Physicians will be forced to follow these new guidelines and essentially become slaves to the machines....

frankbill said...

A. Banterings Can you provide the place you got your information about your quote.

One of the goals of EHR is to create a library of evidence based guidelines. Physicians will be forced to follow these new guidelines and essentially become slaves to the machines....

A. Banterings said...


You have to read between the lines. ACA requires measurement of effective outcomes. AHRQ integrates evidence based decision making assistance with EHR systems. Part of measurement of effective outcomes involves if evidence based treatments (of the AHRQ) are followed or not.


Electronic health record: integrating evidence-based information at the point of clinical decision making (Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3878937/)

Measure Once, Cut Twice – Adding Patient-Reported Outcome Measures to the Electronic Health Record for Comparative Effectiveness Research
(Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779680/)

U.S. Agency for Healthcare Research & Quality (AHRQ):

ePSS Electronic Preventive Services Selector
(Link: http://epss.ahrq.gov/PDA/index.jsp )

The ePSS is an application designed to help primary care clinicians identify clinical preventive services that are appropriate for their patients. Use the tool to search and browse U.S. Preventive Services Task Force (USPSTF) recommendations on the web or on your PDA or mobile device.

Module 17. Electronic Health Records and Meaningful Use
(Link: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod17.html)

The American Chiropractic Association (ACA):

Medicare: Quality
(Link: http://www.acatoday.org/content_css.cfm?CID=2296)

The ultimate goal of all parties is to have effective outcomes measures.

University San Francisco:

Evidence-based Change in Practice: Development and Implementation of Type II Diabetic Flow Sheet
(Link: http://repository.usfca.edu/cgi/viewcontent.cgi?article=1048&context=dnp)


2015 Physician Quality Reporting System
(Link: https://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system.page)

Policy Options to Encourage Patient-Physician Shared Decision Making
(Link: http://www.nihcr.org/Shared-Decision-Making)

Improving Health Care Outcomes through Personalized Comparisons of Treatment Effectiveness Based on Electronic Health Records
(Link: http://onlinelibrary.wiley.com/doi/10.1111/j.1748-720X.2011.00612.x/abstract)

Skeptical Scalpel said...

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