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A landmark article

Doctors at Johns Hopkins usually don't have radical ideas, but this time is different
Illustrative. A patient kept in a corridor due to overcrowding at a hospital. (Tsafrir Abayov/ Flash90)
Illustrative. A patient kept in a corridor due to overcrowding at a hospital. (Tsafrir Abayov/ Flash90)

It is not often that one comes across a landmark paper in any field of study. By definition, a landmark paper changes things. It fundamentally resets a way of thinking or a means of practice that have been held to be “the truth” until the landmark paper was published. What’s really fascinating is when you come across a landmark paper that is not recognized as a landmark paper. Sometimes it takes years if not decades to appreciate how critical a particular study was. Often times, a Nobel prize will be decades in the making until a particular piece of research is appreciated for all of its true value.

The following article represents a very extreme point of view that only a top research and clinical center could have. Johns Hopkins Hospital is recognized as one of the top hospitals in the world. Therefore, when such a hospital comes forth with a statement that is sweeping, it begs recognition and demands either a positive or negative response.

Simply put, the powers that be from Johns Hopkins are now stating that surgeons should stop performing procedures they do infrequently. At the moment, the future of Obama care rests on four words. I would argue that the future of medical practice now rests on less than 10 words. What is critically important about such a statement from Johns Hopkins, is that it is relatively easy to validate with hard data. It is not difficult to quantify the years of experience that a particular surgeon has. One then correlates this value to a quantification of the outcome of the patient. This can be expressed in terms of mortality, number of wound infections, length of stay in the hospital, and many other parameters. The point is that this statement has actually been long in coming. And it will change the way doctors in all fields, practice their art.

Of course such a statement poses a self-referential problem. If it becomes that, eventually, it should be only surgeons with vast experience that perform a particular procedure, then where are surgeons meant to gain that experience? In theory, you could designate that only a few centers in a particular country are certified to train surgeons. In such a situation, every young resident would be paired with a very experienced surgeon and every movement of that young resident would be carried out under the ever watchful eyes of the senior surgeon. Over time, as in any apprenticeship, the young resident would be transformed into a highly qualified practitioner. I have no doubt that under such a model, quality of care for those operated on in this manner, would drastically go up.

There are obviously certain logistical problems with this approach. First of all, the number of certified centers would be relatively small. Anyone wishing to study surgery would have to uproot their life and find a place in one of these few centers,which admittedly, residents are willing to do. The absolute number of positions would be limited which would lead to a drastic shortage of surgeons within a few years. Then, one would be faced with the following statistic. One would be required to ask what is worse: to be operated on by a less experienced surgeon or to only have access to an experienced surgeon after many months, if not more, of waiting. At some point in this statistical analysis, the “beams would cross” and the best values for number of centers versus experience of surgeons not trained in a major center would be expressed.

I noted at the beginning that, sometimes, a landmark paper is not fully appreciated for its value at the time that it is written. I would argue that this article will be the foundation for the elimination of human involvement in healthcare. Whether it takes one or five decades, eventually computers/robotic care will be found to be clearly superior to human driven care. Once deep learning systems are combined with the necessary robotics, it will be possible to train a surgical robot in the same way that a young resident would be trained in one of the certified centers, as I described above.

As I’ve noted in the past, one of the key features of computer systems is that they can multitask and share information. That means that you could simultaneously train tens of such computerized surgeons, and they would end up sharing and combining their experience. That means training 20 robotic surgeons for five years would be equivalent to training one surgical resident for 100 years. The truth is that surgical robots could learn from poor technique just as much as they learn from excellent technique. As long as the surgical robot has access to outcomes, it could easily come to the conclusion that cutting a particular piece of tissue is either a good approach or a bad one. When you combines such surgical robots with real-time ultrasound and previously performed CT and MRI analysis of the patient’s anatomy, the likelihood of such a system outperforming humans goes up dramatically.

The time will come when it will be undeniable that surgical robots perform surgery far better than any human. Humans will continue to argue that there is some element of je ne sais quoi that still makes them superior to the robots. At that point, someone will pull out this article and express the opinion of Johns Hopkins. As long as one can quantitatively show that the outcomes of a particular training approach in surgery is superior to another, then the superior approach must be adopted. It will effectively be with the stamp of approval of Johns Hopkins that surgeons will have to lay down their scalpels and accept the superiority of the surgical robot, because the surgical robot will generate far better outcomes than any human. It will be literally unethical for humans to operate on a patient, given the superiority of the surgical robot. And once again, it will be the senior staff of Johns Hopkins that have blazed the way towards this elimination of human surgeons.

Clearly, I welcome these types of articles because the time has come for doctors to recognize that there are absolute measures of quality, and no one should be allowed to perform below such a level. Yes, at times one will allow themselves to accept substandard care because the option will be no care. But once surgical robots become widespread, every person in the world will have access to top quality surgical care. Once again, it will simply be unethical not to use surgical robots. And in a few decades, surgical robots will be inexpensive enough to make them a viable option for any point in the world.

I suspect that the authors of this article might challenge my logic. That is their right. But my argument holds and the path has been set. Now, it is just a matter of time.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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