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Concerns raised by super-high volume surgeons

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Posted 10/7/2017 3:08 AM (GMT 0)
On another thread, a member raised an important concern about the "mass production lines" for robotic prostatectomies as described in some recent media reports:

newyork.cbslocal.com/2017/05/04/simultaneous-surgery/

nypost.com/2014/04/13/citys-hospital-specialists-are-raking-in-millions-of-dollars/

High volume surgeons are the best surgeons, but at some point there has got to be diminishing marginal returns. Questions come to mind like:
- Is my surgeon actually doing the surgery?
- Is he doing "simultaneous surgeries"?
- Is he taking enough time and care with each surgery, or is it "slam, bam, thank you man."?
- Is he taking on patients whether or not the patient is appropriate for surgery?
- Has he been improving techniques or doing just enough to get away with?
- Is he slowing down the operation to get frozen sections?

I'm not saying media stars and surgeons with hypomanic or obnoxious personalities can't be great doctors too. But that's really a matter of personal "fit." I prefer nerds who approach each patient with curiosity and compassion, and those who practice shared decision-making, not just because they're taught to in medical school, but because they genuinely respect the patient.

I think something has been lost in the transition to robotic surgery, and it's more than just haptic feedback. I think that when one human being has his hands inside another human being there is an important interpersonal relationship formed, one of care and responsibility. It's way too easy now to regard the patient as a thing, instead of a person like himself.
Posted 10/7/2017 3:10 AM (GMT 0)
If I had to do it again, I probably would have gone to my local urologist. Not knocking my procedure, other than I didn't really have a chance to meet with Tewari after ... with my progression, I wish the person who I was consulting with now was the same person who did the original procedure and was local.
Posted 10/7/2017 3:34 AM (GMT 0)
Agree with you TA.

I visted one super high volume surgeon in north FL. He gave me all of 7 minutes, was both dismissive of my questions and very rushed. His facility and staff were very good, but no thanks!

Another celebrity, high volume doc in NYC spoke to me twice over the phone. He was full of himself and recommended procedures I already had done. He didn't take Medicare, and was under investigation for false claims. No thanks, again.

Robotic surgery and DiVinci surgeons are, for the most part, impersonal in my experiences. open surgeons with solid experience are becoming hard to find. Their stats are, on average, better than robotic surgeons.

Good observations.
Posted 10/7/2017 4:55 AM (GMT 0)
Good question. As a recent patient of a "high volume surgeon in north FL," let me put in my two cents:

-- The surgeon and the PA both told me that that the surgeon himself does the surgery. My understanding from articles I've read is that his team preps the patient (places the trocars, insufflates the abdomen) and closes. While he's removing the prostate of one patient, the team is prepping the next. That's how he manages to do 8 or 9 a day.

-- The surgeon himself didn't spend much time with me in the pre-op or post-op consults (7 minutes sounds about right). Even so, I didn't feel rushed, he made good eye contact and his responses to my questions were appropriate and thorough. It's fair to say he wasn't terribly personable, but his PAs and RNs more than made up for it. Didn't particularly bother me.

-- The initial consult, by telephone (I live halfway around the world from FL), was not with the surgeon but with another physician on his team. That physician gave me and my wife almost an hour, and my impression was he'd have stayed on the line even longer if we'd had more questions for him. My sense is the surgeon has structured his practice to leave the touchy-feely stuff to his team, who are extremely good at it, perhaps so he can focus on the surgery itself or perhaps recognizing that they're better at bedside manner. Whatever. I was OK with it.

-- One might think a high-volume superstar surgeon would be unduly cautious about taking on a high-risk patient who might hurt his success rate. One of his other patients told me he felt like he'd won the lottery b/c the surgeon wouldn't have agreed to take him if he was a "bad" case. I'm not buying that myself -- as a Gleason 8 at biopsy, I was never a safe choice for one-and-done surgery. But it's interesting to think about.
______________________
Age 60
PSA 7.2 Apr 2017
Dx July 2017 after biopsy G8 (4+4), 5/13 cores
RARP Aug 11, 2017
Post surgery pathology: pT3a, tumor 30% of gland, seminal vesicles and 3 lymph nodes clear, bone scan clear
PSA 0.13 9/25/2017
Posted 10/7/2017 7:18 AM (GMT 0)
Much of this controversy concerns Dr. Samadi, who is the focus of an investigation of double-booking of surgeries. Here is a recent story about Samadi:

https://www.bostonglobe.com/metro/2017/10/04/federal-prosecutors-launch-investigation-prominent-surgeon-who-double-booked-operations/1JlY3jOAKWURFZczez2s1J/story.html

When I met with Samadi, he said that no one but him ever touches the robot. The above story confirms as much, with the residents working under him complaining that he never teaches them robotic surgery:

"Six medical personnel told the Globe early this year that urology residents do the vast majority of Samadi’s nonrobotic surgeries, including two-hour operations to trim away excess prostate tissue blocking urine flow.

"In fact, residents who train in Lenox Hill’s urology department complained in an anonymous 2015 survey that Samadi wasn’t teaching them the intricacies of robotic surgery at all, according to medical personnel and a letter written by the agency that accredits residency programs, called the Accreditation Council for Graduate Medical Education, or ACGME."

So, if you go to Samadi for RRP, he will do it, but if you are there for something else, it's possible that the residents will be doing the operation.
Posted 10/7/2017 8:30 AM (GMT 0)
My opinion is that I want a skilled surgeon who spends time making me comfortable with what he is going to do. I do wonder about how one can stay focused during long days. Say a doc does three in a day, do you want to be first, second, etc. I am probably going to have surgery and my doc is compassionate, experienced, and works in a world class hospital (Yale). Denis
Posted 10/7/2017 10:47 AM (GMT 0)
I don't expect surgeons to be warm personable individuals--many of them aren't wired that way. Much has been written and said on this aspect, and some surgeons themselves have written that they intentionally put up an emotional wall so that they can perform surgery. If they let themselves get emotionally involved with a patient, then they can't bring themselves to cut into them.

That being said, this aspect of doing surgery on an assembly line seems a bit TOO mechanical. I think we all know that the lead surgeon rarely does the entire procedure start to finish. The team of residents, fellows, and nurses prep us, strap us to the table, stand us on our heads, make the opening incisions, and get things to a defined point before the lead surgeon takes over. If we think it's some other way, then we're deluding ourselves.

At some point, if speed and body count become the measure of success, then 'doing it right' has to suffer. At least that's how it sounds to me.
Posted 10/7/2017 12:15 PM (GMT 0)
Europe still has way more open RP's done than RARP because
- RARP is a skill that's tough to learn and takes a lot of time and volume to get to where US is
- RARP equipment is expensive
- based on some studies - both have the same success rates
In the Europe model , personal touch is still maintained.

I only wish I had more personal time with the pathologist who dissected my organ to bits and pieces - I'm sure he knows more than just a 20 lines on a path report
Posted 10/7/2017 12:53 PM (GMT 0)
My da Vinci surgeon (John Davis, MD Anderson) was on-board with robotic surgery from the earliest days and as of two years ago, he had performed over 2,000 RALPs. He operated on me early Monday morning and had one more scheduled for the afternoon. Tuesdays are his clinic days and I assume there's some teaching time involved since he's an Assistant Professor at UT School of Medicine. He probably operates on other days of the week.

I think the major difference between Roberts and the other high volume da Vinci operators is the almighty dollar. Davis (and everybody else at MD ANderson) is salaried. Obviously the more surgeries the high volume Docs perform, the more money they make. I'll let you draw conclusions.
Posted 10/7/2017 1:12 PM (GMT 0)
My surgeon was Dr Ash Tewari, one of the "rock star" high volume Surgeons. I found him, and still find him, personable, and attentive, a great bedside manner. To this day, on my follow ups, he gives me as much time as I need.
I asked him at my first visit, if he does the entire surgery. His response was that the residents that assist him set me up, position the robot arms, and close up. But nobody touches the robot controls except him. I believe him, maybe because I want to, maybe because I trust him.

He does surgery 4 days a week, and only sees patients in Friday's, as far as I know. I asked to be scheduled as his first surgery of the day, and was told that would happen, and to be at the hospital at 7am. I wasn't taken until noon, and was later told, (at a follow up) that I was his third of the day, because he wanted the other 2 done first, no clue why.
That p!ssed me off. But whatever.

In a perfect world, a surgeon does one a day, and it's done after he gets 8 hours sleep, has son]me coffee, gets some relax time with a newspaper, then strolls into the OR completely relaxed, alert and psyched. But the world is far from perfect. That just isn't the way it is these days. And part of it is the reimbursement system.

Tewari got paid $2300 for my surgery. With his staff, and overhead, the hospital he works for would be in financial trouble if they worked in a perfect world. And he wouldn't get paid what he gets paid.
Posted 10/7/2017 1:48 PM (GMT 0)
Interesting thread. Here's a few thoughts and comments in no particular order.

NY Post article is a big nothing to me. The Post generally aims to shock its readers rather than inform. I'm not surprised that top surgeons in NYC earn millions of dollars a year. So do top executives, top lawyers, and so on. The article compared him Wall Streeters. Not quite. The captains of greed at Wall Street earn hundreds of millions and sometimes more than a billion a year.

Samadi was recommended to me by a friend, but I was turned off by his excessive self promotion. That's just me. I don't think there's any question but that he is an excellent surgeon.

I had robotic heart surgery at Lenox Hill in 2011, and my surgeon was absolutely super. I never felt that he was not giving me enough of his time or attention.

The surgeon who did my prostate at NYU is very experienced and one of the top prostate surgeons in NYC. He doesn't have the "hail fellow well met" bedside manner, but I wasn't looking for a drinking buddy. He's very no nonsense and I like that. And he is generous with his time. A short while ago I had a question after our three month follow up appointment. I wrote to him on "MyChart" (NYU's portal) and he wrote a very thorough, 1,437 word response. Coincidentally, he wrote me a short note just 25 minutes ago in response to my update to him, which required no response at all. I couldn't be more pleased with him. (Not to mention that the surgery turned out well.) Overall, I have been very pleased with NYU.

I'm a proponent of robotic surgery, no doubt because of my own good experience with two robotic surgeries. But it's critical that the surgeon be experienced with the machine. You don't want someone with a learner's permit at the controls. I'm handling a case where a surgeon botched removal of a kidney tumor with the DaVinci (at a world renowned hospital.) Outcomes by experienced robotic surgeons are as good or better than open surgery. There is a reason top surgeons use the machine.

Saipan: just curious . . . your signature has your stage as pT3a. What was it in your pathology that landed you there?

Halbert: I completely agree with you. You can't expect the lead surgeon to do all the scut work, but you don't want his priority to be the number of surgeries he can do in a day.
Posted 10/7/2017 7:07 PM (GMT 0)
Good topic.

My robotic surgery was done by a highly experienced surgeon at U of Chicago. I understand people come from all over to see him. I'm sure some see him as a rock star.

I debated between open and robotic, and chose robotic because some aspects made more sense to me. In general, outcomes are virtually the same. Once I decided on robotic, I chose my surgeon because several people I knew had gone to him, all with decent outcomes. I also went with the most experience I could get as I was aware the learning curve was 300 or so RRP's. Whether it was open or robotic, experience matters.

He was professional in his dealings with me, and gave me enough time over two appointments to answer all my questions. He came across as very confident and someone who knew his business. He wasn't a touchy, feely type, but that didn't matter to me.

He told me his residents would do some of the prep work, but he did the important parts like removing the prostate. He operates two days a week, and does two cases on a day. While I didn't see him right before my surgery (a negative in my book), he had time for my wife after the operation and gave her a report on what happened.

I don't think he is super high volume. Does he do many of these operations? Yes, but I felt comfortable with him. At this point I like my outcome, and would recommend him to others.

I'm enough of a cynic that if I felt my Doc was part of an assembly line approach, I would have gone to someone else.
Posted 10/7/2017 10:24 PM (GMT 0)
My oncology urologist practices at two different hospitals. One more convenient and less expensive then the other one. I had to make a choice for my robotic surgery, and it boiled down to one question I asked him. Do urology residents take part in the surgery? He said "yes" at one hospital and not at the other hospital. Since robotic surgery has a steep learning curve, I wanted my doctor to do the entire surgery (plus that is what I am paying him to do.) So I selected the hospital that wasn't as convenient and was more expensive just so he can do the entire procedure.
Posted 10/7/2017 11:47 PM (GMT 0)

Tall Allen said...
I think something has been lost in the transition to robotic surgery, and it's more than just haptic feedback. I think that when one human being has his hands inside another human being there is an important interpersonal relationship formed, one of care and responsibility. It's way too easy now to regard the patient as a thing, instead of a person like himself.

I've never heard this put into words before. There was something drawing me towards open vs. robotic that I could never put into words. And ... *this* is it. It had to do with connection and trust.

thanks

(just one more place where I put convenience and popular opinion over my own instinct...but...that a personal problem lol) thanks ta smile
Posted 10/7/2017 11:52 PM (GMT 0)
open just felt more "organic" to me. And I'm kind of an organic kind of guy. (probably why I didn't choose radiation...as tempting as it was)
Posted 10/8/2017 2:45 AM (GMT 0)
nyc lawyer asked: "Saipan: just curious . . . your signature has your stage as pT3a. What was it in your pathology that landed you there?"

Biopsy on June 29 had me at pT2b. My urologist strongly recommended RP asap, and I took his recommendation. Post-surgery pathology came in at pT3a. Went with Patel over a couple of other surgeons in FL (where my family is) because his office worked smoothly and compassionately with me as an international patient, and they were able to schedule me for surgery quickly, on August 11.

An aside: about a week after my Guam urologist told me I needed a biopsy (based on high PSA and DRE), I happened to be traveling on the East Coast and saw a Cleveland Clinic urologist in FL for a second opinion. He concurred, of course, and I asked him about open v. robotic. He said the outcomes were about the same, what mattered is getting a highly experienced surgeon. I asked for names in FL, and he replied, "I can recommend several surgeons who do robotic here, but I don't know anyone who still does open!"
Posted 10/8/2017 3:14 AM (GMT 0)
Sorry, nyc lawyer, I think I misunderstood your question. What landed me at pT3a is EPE, seminal vesicles clear.
Posted 10/8/2017 6:38 AM (GMT 0)

island time said...

Tall Allen said...
I think something has been lost in the transition to robotic surgery, and it's more than just haptic feedback. I think that when one human being has his hands inside another human being there is an important interpersonal relationship formed, one of care and responsibility. It's way too easy now to regard the patient as a thing, instead of a person like himself.

I've never heard this put into words before. There was something drawing me towards open vs. robotic that I could never put into words. And ... *this* is it. It had to do with connection and trust.

thanks

(just one more place where I put convenience and popular opinion over my own instinct...but...that a personal problem lol) thanks ta smile

Island time, you have absolutely nailed it.

I also went with what seemed convenient and popular without having investigated my options.

TA's comment made me realise why I was so unhappy with my treatment. Laparoscopic surgery (not robotic) but still not hands on. My surgeon never ever actually touched my “bits” so in my mind, never formed that “interpersonal relationship”.

I may be biased, but my outcome wasn't great whereas a couple of friends who had open surgery have done very well. Of course there are many other factors involved, but TA's statement regarding the personal relationship is something I find very profound.

Chas
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