A colleague of mine, when faced with yet more guidelines and protocols to follow, once said ‘I’m a doctor, not a robot!’. Jokes about doctors being replaced by robots or computers are not new, but the reality may soon be upon us. Lord Darzi, the man charged with saving the NHS, is very keen on robots assisting his surgery. They don’t suffer from fatigue, very few get drunk or throw scalpels at the scrub nurse and they’ve never been known to get the shakes. In prostate surgery, they’ve long been used for delicate work to spare the nerves and thus minimise the risk of incontinence and impotence.
In 1996, Hans Ohlin, the chief of coronary care at the University of Lund Hospital, took on a computer in the analysis of ECGs—the medical equivalent of the chess contest between Gary Kasparov and Deep Blue.1A total of 2240 ECGs were selected for analysis, of which 1120 were from patients known to have had heart attacks. The top cardiologist in Sweden correctly identified 620. The computer picked up 738. In a health system that relies increasingly on technology, it seems human clinical brilliance is being edged out by electronic wizardry.
And so it is with hair transplants. Restoration Robotics of Mountain View, California, can apparently perform hair restoration procedures twice as quickly as a team of doctors, with less pain and scarring. Restoration Robotics’ cameras and 3-D imaging software give a far clearer view than an ancient surgeon’s varifocals, allowing it accurately to harvest and reimplant one follicle at a time.2
To take on the robots, humans may have to behave more like them. The theory behind evidence-based guidelines is that we consistently treat patients with the same illness in the optimal way. I recently interviewed the American surgeon and writer Atul Gawande, who described a ‘hernia factory’ at Shouldice hospital near Toronto, which had devoted itself to the machine-like perfection of surgery. Humans were still carrying out the procedure but hernia repair was the only thing they did, and they had perfected their technique. The operation took half as long as the North American average, cost half as much, and had an astonishing 1% recurrence rate.3
The surgeons, it seems, were happy to abandon the variety of clinical freedom and just operate on hernias, motivated by their pursuit of excellence. They had researched the best technique, perfected it, published their results, and got on with the job with an unerring (some would say unnerving) efficiency. Although most doctors delight in their human side, and the humour and creativity that makes us stand out from machines, there is much we could learn from them. Gawande is spearheading an initiative from the World Health Organization on the use of checklists for surgery, which makes a real difference to post-operative infection and complication.4It shares its theory with the standard operating procedures that pilots use. There is ample evidence that when things go wrong in the air or in the NHS, then great teamwork and swift, calm adherence to tried and tested protocols can avoid disaster.
Perhaps doctors should be more like robots. While the media and medical soap operas focus on high emotion and heroic surgery, it is the calm, repetitive adherence to best practice that keeps us safe, and chronic illness at bay. Pretty dull television, admittedly, but we need to learn to value it just as much.
- Hedén B, Ohlin H, Rittner R, Edenbrandt L. Acute myocardial infarction detected in the 12-lead ECG by artificial neural networks. Circulation 1997; 96 (6): 1798–1802.
- Gawande A. No Mistake. Medical Dispatch, The New Yorker, March 30, 1998, p. 74. www.newyorker.com/archive/1998/03/30/1998_03_30_074_TNY_LIBRY_000015236
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