It’s not just about the patient: a less spoken argument on the cost and benefit of robotic surgery

Contributor : Xi Chen, Analyst

Publish date: 19 Apr, 2016

Robot looking at an x-ray on a screen

What is causing the exodus of Canadian physicians to the US? Some say it’s pay. Some say it’s training. Although it might actually just be a myth. Last week, I met up with two friends nearing the end of their general surgeon residency.  Both are really really really tired. Both are unsatisfied with the training they are receiving here in Toronto. One learned a lot of her surgical techniques by watching YouTube because fellows just don’t have the time and more importantly, incentive, to mentor them. Lack of training translates to lack of opportunities in the operating room, which feeds back to a lack of training in a vicious circle.

To be fair, residents in the US are not doing that much better either. But there is one aspect where the US is miles ahead: robotic surgery. Both of my friends lamented on the utter lack of robots here in Canada and drool at the prospect of using one if they were to move to the US. Would you put your life at the hands of a YouTube-trained surgeon or a robot operated by said surgeon? I lean toward the second option. You may want neither, but sometimes you don’t have a choice.

Speaking of robotics, cost continues to be main argument against its adoption. Nobody wants a black hole for health care spending. Does robotic surgery have better patient outcomes to tilt the cost-benefit scale? Maybe one in every two procedures. Intuitive Surgical did score big in a recent robotic prostatectomy study that demonstrates long term cost savings by looking beyond hospital costs and into payer and societal costs. However, we still have to admit that robotic surgery, on average, is costly. Therefore, I can only think of two ways to justify the use of robotics: 1) reduce the cost of the equipment, and 2) demonstrate that it is far superior.

Far superior in what aspects? Before one start digging into randomized trials comparing robots to laparoscopy, let us think again about our YouTube-trained buddy who wants to leave Canada for the land of opportunities. To be fair, Canada cannot compete with the 17% of GDP the US spends on health care. In fact, no country in the world can. The Canadian government is awaiting more favorable clinical evidence before considering purchasing more robots. I completely sympathize with this approach because the evidence is clearly not yet convincing. But let me play the devil’s advocate here. What if the biggest beneficiary of robotic surgery is not the patient?

Robotics win hands down when it comes to reducing physician stress, which I have highlighted in the past. Robotics win when it comes to attracting young talents (see above). Robotics win when it comes to training. Long gone are the times when patients would willingly submit themselves as “guinea pigs” for doctors in training. Residents no longer get enough hands on training and have to make do with being an observer or at most an assistant in the operating room. Basic skills must be learned and practiced in a simulated setting. Simulators for manual laparoscopic surgery do exist, but these machines are costly and are not a close representation of the actual surgical procedure. In robotics, simulation experience can be more readily transferred to actual surgery because the same console is used, resulting in a shorter learning curve than manual laparoscopy. In fact, inexperienced medical students can perform much better with a robot than manual laparoscopy, as shown in this study. Robots are not just easier for these residents; they may even be safer.

This argument has gotten a bit lost in the whole debate about the benefits of robotic surgery. We are surrounded by buzz words such as “evidence-based medicine”, “patient centricity”, and “cost/benefit analysis”. There are tons of randomized trials comparing robots to laparoscopy, how many have addressed the effects of surgeon fatigue or inexperience? Perhaps residents are becoming more relegated to the periphery of operating rooms for issues of “inexperience” to manifest in these trials. This is precisely the problem we are facing today: so many young surgeons are coming through the education system but the value they could add to our health care is not realised. These surgeons’ careers are being shortened by starting too late due to inadequate training and ending too early due to fatigue, presenting an economic impact that that has been largely neglected.

Fortunately, the world is catching up with the paradigm shift of replacing doctors’ arms with robotic ones. Since the skeptical post I published a year ago, robotic surgery has done extremely well. Compared to 2014, robotic procedures went up by 14% and Intuitive Surgical bagged 12% more revenue in 2015. Start-ups and megacorporations are popping up left and right, vying for a place in one of the fastest-growing medtech markets today. TransEnterix’s SurgiBot got very close to getting its robot FDA approved in Q1, but we will have to hold our excitement for at least a couple of more weeks. Expectations can still be dashed; the FDA may still deny SurgiBot’s approval or request more clinical trials. But it is hard to imagine that the FDA will give up on the opportunity to have another competitor in the market. Hospitals and payers are also eagerly waiting for a new device that can drive down the cost of robotic surgery.

As mentioned earlier, there are two routes to justify the use of robotics: 1) reduce the cost of the equipment, and 2) demonstrate that it is far superior. TranEnterix’s SurgiBot is certainly going down the first route. It cost almost half as much as Intuitive Surgical’s Da Vinci in both upfront capital installation and per-procedure consumables. SurgiBot also boasts technological improvements such as haptic feedback, portability, and bedside access. However, cost is not entirely defined by capital installation and consumables thereafter. Spending on capital installation can be mitigated if you can get it to perform 10 types of procedures 10 times a day (unlike this poor fellow). In other words, success is not only dependent on the price tag but also how versatile the system is. A robot that is customizable and capable of handling different types of surgery will be a robot that is hard to beat in the market. In consideration of this, Intuitive Surgical still has the edge, while SurgiBot’s single-port design might become its Achilles heel. While the impact of new entrants like TransEnterix is yet to be seen, I am certain one day we will all be convinced that robotic surgery is worth every penny we pay for.

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