More Looking Out for Your Own Wellbeing

Are you better at chopping onions or folding laundry? Doc Gumshoe learns from the sad story of the Shah.

[ed. note: Michael Jorrin, who I call Doc Gumshoe, is a longtime medical writer (not a doctor) who writes for us about medicine and health a couple times a month. He has agreed to our trading and disclosure restrictions, but does not generally write directly about investments. His ideas, thoughts and words are his own, and you can see all his past pieces here.]

At the end of the previous Doc Gumshoe installment, I promised to reflect on what Marty Makary, MD, wrote about in his recent book, Unaccountable.   The book is primarily about the lack of transparency that affects the entire medical field when it comes to the question of the individual performance of many of those practitioners into whose hands we entrust our lives.   This is especially true of physicians who perform procedures that demand a high degree of skill.   Makary himself is a surgeon, practicing at Johns Hopkins Hospital, and he recounts a great many specific examples of that lack of transparency and how it can result in significant harm to patients.       

A great deal of what physicians learn might be classified as book learning enhanced by practical demonstrations and experience.   They learn anatomy by the book, but they also study anatomy by dissecting cadavers, and they go on to relate what they have learned to actual experience with living patients.   From the outside, they know how your organs and bones and muscles and nerves and blood vessels all fit together.   But that doesn’t mean that they’re competent to pick up a scalpel and slice into your body and find your spleen and remove it (without spilling any potentially harmful fluids) and then put all your parts back together and send you home good as new, or nearly good as new. 

It should be obvious that surgery and other interventions of that sort demand highly specific skills and dexterity, which cannot reliably be predicted by a physician’s academic training.   And these skills are indeed highly specific; my excellent knee surgeon, for example, does not do coronary artery bypass grafts (CABG), nor does the cardiac surgeon do knees.   Interventional cardiologists can place stents in coronary arteries, but actually opening up the chest cavity and replacing a section of a coronary artery may be beyond their skill level.   Moreover, skill levels are not merely a matter of education and training.   Underlying dexterity, as well as character and disposition, also has quite a lot to do with it.

A trivial example may cast some light on what I’m trying to say: I happen to be the best dicer of onions of anybody I know, and probably the best peeler of mangoes in the state (there may be better ones across the state line).   But when it comes to tying neat little knots in tiny bits of string, or folding laundry, I am a clumsy oaf.   I have one kind of manual dexterity, but not the other.   Also, the end products matter to me differently – food outranks neatly folded laundry in my prioritized value system.   But you cannot tell from my academic records or my résumé how good I am at dicing onions, nor yet how bad I am at folding laundry.

Returning to Dr Makary’s interesting (if disquieting) book, he cites a number of examples in which patients wound up in the hands of the wrong doctors for a wide variety of reasons.   The circumstances that led to these wrong choices are such that any of us could find ourselves in similar positions, undergoing vitally important procedures under the wrong hands.

Most of these particular instances passed under the radar.   Sometimes not even the patients themselves were aware that the poor outcomes they suffered from their procedures could have been easily avoided, had they been treated by a more skilled and experienced practitioner.   But one example did receive a great deal of attention, including international attention at the highest levels, although the specific nature of the error was not widely publicized at the time.   That was the surgery performed on the Shah of Iran, His Majesty Mohammed Reza Pahlavi, by the physician who at that time was probably the most eminent surgeon on the planet, Dr Michael DeBakey.

What was special about Dr Michael DeBakey?

To remind those of us whose recollection of DeBakey is a bit spotty, here are some excerpts from his obituary in the New York Times: 

“ ‘Many consider Michael E. DeBakey to be the greatest surgeon ever,’ the Journal of the American Medical Association said in 2005. By the time Dr. DeBakey stopped a regular surgical schedule, when he was in his 80s, he had performed more than 60,000 operations. …

Dr. DeBakey’s surgical innovations have become common practice today and have saved tens of thousands of lives. An early invention, the roller pump, devised while he was in medical school in the 1930s, became the central component of the heart-lung machine, which takes over the functions of the heart and lungs during surgery by supplying oxygenated blood to the brain…. 

Yet he achieved his fame as much for what he did outside the operating room as what he did in it. His care of ailing world leaders, like President Boris N. Yeltsin of Russia, made headlines. …

In his public and professional lectures, Dr. DeBakey, an inveterate name-dropper, often showed photographs of his celebrated patients and spoke about their ailments. Among these notables were the deposed shah of Iran, Mohammed Reza Pahlavi; the duke of Windsor, the former King Edward VIII of England; Marlene Dietrich; Joe Louis; Leo Durocher, the baseball manager; and Jerry Lewis. …

Dr. DeBakey was a pioneer in performing coronary bypass operations. In one of his last lectures, at the New York Academy of Medicine in Manhattan in November 2005, Dr. DeBakey said that his team had performed the first successful coronary bypass operation, in 1964, but that it did not report it until 1974.… His team was the first to transplant four organs (a heart, two kidneys and a lung) from one donor to different recipients….

Dr. DeBakey was a perfectionist, intolerant of incompetence, sloppy thinking and laziness. Before mellowing in his later years, he had a reputation for sometimes tyrannical behavior in firing assistants for making relatively minor errors like cutting a suture to the wrong length.

‘If you were on the operating table,’ Dr. DeBakey said, ‘would you want a perfectionist or somebody who cared little for detail?’ ”

Dr DeBakey and the Shah of Iran

Makary describes the interaction between the eminent surgeon and the Shah briefly before moving on to a discussion relating to his overall topic, which is the absence of good information which would help patients make intelligent decisions as to who should perform surgeries and similar procedures. After emphasizing the importance of the Shah in advancing the interest of the United States in the Middle East, Makary describes the incident as follows:

“When the Shah suddenly fell ill, Washington faced a potential international crisis.   Pahlavi was admitted to a fourteen-suite VIP floor at a well-known Middle Eastern hospital.   The U. S. acted swiftly to ensure that he got the best care.   A medical team including David Rockefeller’s private doctor and DeBakey sped to the Middle East in a chartered Boeing 707 to pick up the Shah.   The key world figure and the world-famous surgeon seemed well matched.

Upon seeing the Shah, Dr. DeBakey recommended immediate surgery to remove his spleen.   The main pitfall of any spleen operation is the possibility that the surgeon could inadvertently cut the tail of the pancreas, which lies in direct proximity to the spleen.   This can lead to a fatal infection weeks later from the pancreas slowly leaking pancreatic fluid.   Standard good practice has long called for the surgeon to place a surgical drain in the area of the pancreas to prevent pancreatic fluid from accumulating in case it is inadvertently cut.

Dr. DeBakey did not take this simple, standard safety measure.   Even though the Shah’s spleen was exceptionally large, increasing the risk of a pancreas injury, DeBakey refused to leave a drain, as he was confident he would never touch the pancreas.   After the one-hour-and-twenty-minute operation, he reported that it went ‘about as smoothly as you could make it’ and that the Shah ‘couldn’t be better.’

For his successful operation, Dr. DeBakey received a heralded medal of honor from the president of Egypt, the highest honor for a civilian.   Soon after DeBakey received these kudos, however, the Shah began to experience fevers and vomiting.   Then he got worse.   His local Egyptian doctors sampled the fluid that had built up in the area of the operation and determined that it came from a leaking pancreas.   The fluid had accumulated and as a result became infected. …

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Under pressure from Egypt and the United States, Dr DeBakey returned to see his now deteriorating patient.   The Shah had lost a lot of weight and looked terrible….   But Dr. DeBakey refused to believe that the Shah had a pancreatic fluid leak, telling the Shah’s family that his malaise was likely due to toxicity from medication that the Shah was receiving against Dr. DeBakey’s recommendation….

After a three-month delay in diagnosis littered with controversy, a French surgeon reopened the Shah’s wound and let out 1.5 liters of pus and infected pancreatic tissue.   It was clear that Dr. DeBakey had inadvertently cut the pancreas during his operation. “

Makary’s narrative of this incident is brief and omits a great many details that are relevant to our overall subject. Among the details that Makary omits is that the trajectory from the Shah’s initial illness to his death spanned more than six years, from early 1974 to DeBakey’s surgery on March 28, 1980 and the Shah’s death on July 27, 1980. The entire history is presented in painstaking detail in a paper in the Alexandria Journal of Medicine (2016;52:201-208) by Andavan Khoshnood and Arvin Khosnood, both faculty members at Skåne University Hospital, Lund, Sweden. Here’s a greatly condensed version:

In 1974, in Tehran, the Shah was diagnosed with an enlarged spleen and chronic lymphocytic leukemia (CLL), a slowly progressing form of cancer.   His personal physician, Dr Ayadi, was adamant that the word “cancer” not be used in describing the Shah’s condition.   His symptoms were considered to be consistent with Waldenström’s disease, an indolent condition, and not a cause for immediate concern.   The Shah decided to wait to take any action until his annual checkup in Vienna with a Professor Fellinger, who informed him that he had lymphoma.   Returning to Tehran, he was seen by Professor Georges Flandrin, who had been brought to Tehran by the Shah’s Minister of Court, Asadollah Alam.   Professor Flandrin was the physician who most closely followed the Shah in the ensuing six years, seeing him a total of 39 times.

Later that same year, the Shah’s symptoms increased, and Prof. Flandrin returned to Tehran, where he prescribed chlorambucil, a chemotherapy agent used to treat CLL.   The drug was disguised as an antimalarial drug, Quinercil, to cover up the link with cancer.   In 1975, continuing to feel the effects of the enlarged spleen, the Shah went to Zurich, where once again he was seen by Prof. Flandrin, who increased the dose of chlorambucil.   In 1976, as the symptoms worsened, he was again seen by Prof. Flandrin.   Along about this time it was learned that the Shah’s valet, in the belief that the drug the Shah was taking was indeed Quinercil, ordered the Shah’s prescription refilled as Quinercil rather than chlorambucil.

The following years saw at the same time a gradual worsening of the Shah’s condition as well as increasing political chaos in Iran.   In 1979, the Shah left Iran and went first to Aswan, Egypt, and then to Morocco, the Bahamas and Nassau, and then to Cuernavaca, Mexico, where he was seen by an American physician, Dr Benjamin Kean, a specialist in tropical medicine, who diagnosed the Shah with malignant lymphoma.

The Shah was then transferred to New York Hospital under the pseudonym David Newsome, where on October 24, 1979 he underwent cholecystectomy (surgical removal of the gallbladder); however, his enlarged spleen was not removed.   Still in New York, he was transferred to Memorial Sloan Kettering Hospital, where he received radiation therapy for malignant large cell lymphoma.

In December of 1979, he was taken to Contadora Island off the coast of Panama, where he was seen both by Dr Kean and Dr Flandrin, who were clearly at odds with each other about the Shah’s care.   Flandrin favored surgical removal of the spleen, which was opposed by Kean.   

As the Shah’s condition deteriorated, he was admitted to the Gorgas Hospital in Panama, which was a U. S. Army Hospital, and Dr Michael DeBakey was flown there to perform the splenectomy.   However, the Panamanian physicians who staffed the hospital refused to let DeBakey carry out the surgery, so DeBakey returned to the United States, and the Shah left Panama for Egypt on March 23, 1980.   Three days later, DeBakey and his surgical team arrived in Egypt, and on March 28 the splenectomy was performed.   The spleen weighed almost two kilograms and was riddled with cancerous nodules.   

The Shah’s condition continued to deteriorate.   Flandrin and others suspected a subphrenic abscess (accumulation of fluid in the neighborhood of the liver and the spleen), and suggested that DeBakey return to deal with it, even though the Egyptian physicians how had the primary responsibility for the Shah.   There were three contradictory opinions regarding the essential causes of the Shah’s decline.   Flandrin believed that it was a subphrenic abscess, another physician who had been marginally involved thought it was a Salmonella infection, and DeBakey insisted that it was due to chemotherapy, which was then reduced.

At this point, the president of Egypt, Anwar Sadat, took charge of the situation and pronounced Dr Flandrin as the Shah’s physician.   Dr Flandrin summoned a French surgeon, Dr Pierre-Louis Fagniez, who made a small incision precisely in the area where the fluid had gathered, and drained one-and-a-half liters of pus from the site.   An Egyptian surgeon who had witnessed the splenectomy, Dr Fouad Nour, confirmed that he had seen Dr DeBakey cutting into the tail of the pancreas, and Dr Flandrin verified that statement by identifying pancreatic tissue in the material around the removed spleen.

What went wrong?

Besides the obvious answer – that DeBakey failed to take the elementary precaution of placing the surgical drain around the pancreas in the event that the pancreas was accidentally cut during the surgery – my answer is, just about everything.   Here’s my short list of what went wrong, with my reflections on how the rest of us, who are not monarchs, might learn from those mistakes and thus look out for our own well-being.

  1. Dr DeBakey was not the man for the job.   He was a cardiovascular surgeon, and not a specialist in surgery in the abdominal cavity.   He may indeed have done 60,000 surgeries, but the overwhelming majority of these were cardiovascular surgeries.   When choosing a physician to carry out a procedure, you want one who has performed that specific procedure many, many times.   Practice makes perfect.   You don’t expect Joshua Bell to sit down at the piano and play Beethoven’s “Hammerklavier” Sonata – he’s a violinist, for Lord’s sake! – nor do you expect the pianist Daniel Baremboim to pick up the violin and play the fugue from Bach’s second sonata for unaccompanied violin.   That doesn’t mean that they’re not both excellent musicians, but they have entirely different skills.The relationship between the number of procedures a surgeon carries out and operative mortality has been confirmed by examination of nearly half a million Medicare claims for the year 1998-99. Surgeon volume was inversely related to mortality – the more surgeries of a specific kind a surgeon carried out, the lower the mortality.   For example, patients who experienced pancreatic surgery at the hands of a low-volume surgeon were 3.64 times more likely to die than those whose surgery was done by a higher-volume surgeon. (Birkmeyer JD, N Engl J Med  2003;349:2117-2127)
  2. The decision regarding who is to carry out the procedure in question should primarily be the patient’s, aided by advice from health-care providers, family, friends, etc.   The United States promoted DeBakey because he was our most famous surgeon, and making him available to the Shah of Iran was a political act.   Similarly, the governments of Mexico, Panama, and Egypt seem to have muddied the waters.   In reading the detailed narrative of the events by the Koshnood brothers, I saw very little suggestion that the Shah had much input as to what his treatment should be.   I am confident that not many of us would be subject to specific decisions by presidents or Ayatollahs regarding who will be putting us under the knife, but before subjecting ourselves to all manner of potentially risky procedures, we need to take responsibility for those decisions, which requires seeking information.
  3. The secrecy regarding the Shah’s condition seems to have been a really bad idea. Granted that applying the word “cancer” to all of the great many manifestations of cancer can lead people to the wrong conclusion, namely that the person who “has cancer” is at death’s door. But this was not true of the Shah’s original diagnosis of chronic lymphocytic leukemia, which has a five-year survival rate of nearly 90%. In the Shah’s particular case, disguising his chemotherapy drug as an antimalarial led to his being given the wrong prescription for an indeterminate period. As for the rest of us, it seems to me not a good idea to conceal significant medical conditions from people with whom we are in close contact. That doesn’t mean you have to proclaim to all and sundry that you have a particular disease – you don’t have to be like the leper who walks through the village ringing his bell so that people won’t get close to him.   But it’s a pretty good idea to have your friends have some notion of what ails you.

A few other pitfalls

Makary points to several other ways in which individual patients wind up being treated by decidedly suboptimal practitioners or receive suboptimal care.   It is clearly very difficult for the patient, who is an outsider to the world of medicine, to get confidential inside information on the expertise and skill of any specific practitioner.   The insiders – nursing staff, physician assistants, other physicians – may know a lot about the surgeons and the interventional cardiologists and other practitioners that carry out procedures.   But they’re not going to tell you, unless you happen to be a very close friend or a relative.

In evaluating a physician, the public at large is apt to award a great deal of weight to the physician’s “bedside manner,” whether displayed at the patient’s actual bedside or when conversing with the patient’s family in the hall.   They like the doctor who takes time to chat and seems open and friendly, but they have not the faintest notion of how well this doctor carries out procedures when the patient is under anaesthesia.   On the other hand, they tend to dislike the doctor who is arrogant and brusque.   They don’t know (sometimes) that the first doctor, kind and affable, is a ham-handed clown with the scalpel and forceps, while the unlikeable second doctor is exceedingly skillful and adept.

There are lots of stories like this one, from a physician who became an eminent allergist.   When he was an intern, while performing an appendectomy under the watchful eye of the surgeon, he failed to clamp off the appendix and let it slip through his fingers in the patient’s abdominal cavity, thereby letting the toxic contents of the appendix escape.   Of course, the patient – a teenage girl – developed an infection, and instead of being promptly released from the hospital, she was kept there until the infection was resolved.   During this period, the mortified intern spent a great deal of time at the girl’s bedside and with her family.   Neither the girl nor her family had the slightest notion that her infection was due to that fellow’s blunder.   They thought he was the nicest chap in the world.   He became a friend of the family and was invited to the girl’s high-school graduation.   You can bet that if anyone asked that family to recommend a physician, he would have gotten the nod.

Makary makes the point that the general public, including former patients, knows very little about the actual qualifications of providers and hospitals.   They make their decisions about where to go for treatment based on considerations such as parking, distance from home, whether they treated celebrities, the quality of hospital food, the disposition of the nursing staff, and similar matters that have nothing to do with the quality of care.   On the other hand, health-care workers know a great deal about the quality of care in the settings in which they work.   Makary and another investigator, Brian Sexton, PhD, devised a survey to try to pinpoint quality based on questions to hospital employees.  Some of the questions were:

  • Would you feel comfortable having your own care performed in the unit in which you worked?
  • Do people work well as a coordinated team?
  • Do doctors and nurses do what’s in the best interests of the patient?
  • Do you feel comfortable speaking up when you have safety concerns? 

The key question in this survey was the first one above.   Makary reports that at over half of the hospitals they surveyed, half of the health-care workers said no, they would not feel comfortable receiving care in the units in which they worked.   On the other hand, in some hospitals as many as 99% of the workers said that they would feel comfortable being treated in their units.   It would be nice to know which hospitals those were, but the results of the survey remain confidential.

By and large, specific details about important matters such as comparative death rates across hospitals are exceedingly difficult to come by.   There are exceptions.   Since 1989, hospitals in New York State have been required to report death rates from coronary artery bypass graft procedures (CABG), a commonly performed operation that should be very low risk.   The first year that mortality associated with CABG was reported, the death rates varied from below 1% to about 18%.   Thereafter, even though hospital administrators protested the requirement to report death rates, hospitals made large efforts to improve.   In New York, deaths from heart surgery fell by 41% in the first four years after public disclosure started, and have been declining ever since.

Currently, the Society of Thoracic Surgeons collects reliable heart surgery data from hospitals nation-wide; however, this information is not available to the public.   Without doubt, the fact that the information is available to the world of heart and lung surgeons has resulted in improvement in outcomes, but it doesn’t help the general public in arriving at a decision as to where to be treated.  

A couple of other issues

New ways of carrying out medical procedures are being introduced all the time.   A major emphasis is on minimally invasive surgery.   No longer is it the norm for the surgeon to slice the patient open from sternum to pubis, retract all the layers of skin and muscle and fat, and go to work on the internal organs with everything nicely displayed like an illustration in Gray’s Anatomy.   Nowadays, the smaller the incision is, the better, and best if it’s a small incision and the surgical instruments can be snaked in with a tiny video camera, all of which can be controlled remotely.

Minimally invasive surgery does not necessarily lead to better clinical outcomes than open surgery, because the two forms of surgery are essentially accomplishing the same thing.   But it does take less time, and sometimes considerably less time, because the surgeon doesn’t have to take everything apart and put it all back together.   And, from the patient’s perspective, it generally makes the procedure a good deal less traumatic and recovery a good deal easier and faster.

(This is not to say that there are not drawbacks and risks with some of these minimally invasive surgeries.   The surgeon controls the surgical instruments remotely and sees the operative field on a screen.   There is no tactile feedback, as there is when the surgeon is holding the scalpel in his/her hand.   It is perhaps a bit easier to make a wrong move when the instrument is being manipulated robotically.   In the case of a wrong move, it may be important that somebody be immediately available to correct and complete the procedure as open surgery.)

However, there is no arguing with the fact that minimally invasive surgery presents many substantial benefits to the patient.   But not all surgeons know – or even want to know – how to perform minimally invasive surgery.   This is particularly true of those surgeons who had been performing the same open procedure for a couple of decades before the new minimally invasive procedure was introduced.   They would have to go back for training, and some of them don’t want to take the time or subject themselves to disciplines that they had long put behind them.   They know how to do it their way, they have achieved good results doing it their way, and they are going to keep on doing it their way.   End of story.

In emergency situations, when the patient goes into the operating room, he/she may have no idea whether the surgery is going to take an hour or six hours.   It may depend on the luck of the draw.   But with elective surgery, the patient would do well to do a bit of advance research as to the modes of surgery available, and would also be well advised to ask any prospective surgeon what mode of surgery the particular surgeon is planning to carry out.   The surgeon might not volunteer that information right off the bat, but would certainly disclose the surgical plan if asked point blank.

Another matter raised by Makary is robotic surgery, in which the surgeon sits in a booth in a different room than the patient and moves all the surgical instruments remotely – when the surgeon’s hand moves, the scalpel moves.   The advantages are said to be that the scalpel moves smoothly, precisely, and without tremors.   Robotic surgery has been in use for ten years or so, and the chief advantages seem to be a matter of being able to promote robotic surgery as the most up-to-date way to carry out a procedure that’s been commonplace for a long time.   Disadvantages may be that in emergencies requiring rapid intervention – cardio-pulmonary resuscitation, correction of bleeding emergencies – the robot is a bulky impediment to urgent action by humans.   

These robots are not cheap.   They cost about two million dollars each, and after each use, thousands of dollars worth of parts need to be disposed of.

Regarding robotic surgery, Doc Gumshoe’s skepticism monitor goes into the red zone.

What to do?

I honestly wish I had a better answer.   Makary’s answer is more transparency.   The subtitle of his book is “how transparency can revolutionize health care.”   I would like to think that more transparency is on the way, somehow.   There are certainly many advocates for transparency, and some hospitals are very open about their performance, including death rates and infection rates.   U. S. News and World Report annually publishes its list of the best hospitals in the US.   Not surprisingly, the top five are Mayo Clinic, Cleveland Clinic, Johns Hopkins Hospital, Mass General Hospital, and UCSF Medical Center.   However, even within those hospitals there will be variance between the most and least skillful practitioners.

As to what we as individuals can do to increase our chances of landing the best practitioner for these procedures, it seems to me that we may need to be irritatingly persistent in asking questions and pressing for answers, e.g., “Dr DeBakey, how many splenectomies have you performed?”  And we can delve into the colossal amount of information that’s available on the internet.   As my mother-in-law says, “Ask the computer.” 

And we should not hesitate to solicit second opinions if we feel the least dubious about the proposed treatment.  People may feel that seeking a second opinion, if it should be revealed to the original physician, would be a mark of disrespect and somehow put them in the wrong vis-à-vis that physician, and perhaps that’s the reason that so few patients (fewer than 10%) go that extra mile.   But it’s your life on the line.    

* * * * * * *

On balance, I fear that this installment of the Doc Gumshoe papers is more disquieting than soothing.   That, perhaps, is natural.   The operating room is not where we go for a pleasant relaxing interlude (other than that instant, over in a flash, when we go under anaesthesia).   We should take comfort in the fact that no matter what, we’re better off than the Shah of Iran was.   There are excellent hospitals and excellent surgeons out there, and with diligence, we can probably land in the right hands.   Best to all, Michael Jorrin (aka Doc Gumshoe)



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May 16, 2018 11:51 am

TRXC is coming of age. Has an approved device with great operating features and stock price that is ascending nicely. Travis is right of course about asking the right questions of your physicians. Oversight is critical. There is no best surgeon and and an accurate medical diagnosis is crucial. Case in point was the diagnosis of Q fever endocarditis by telephone consultation and confirmed by appropriate testing. We do live in an amazing age.

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May 16, 2018 12:03 pm

Through the magic of Kindle, I’m already reading the book – and as a retired air safety investigator, I can see the parallels betwen the benefits of confidential safety reporting systems and interventions in aviation as well as the need for them in medicine. There are a lot of similarities: just like doctors, pilots and air traffic controllers are sometimes reluctant to acknowledge that they don’t actually walk on water, and their mistakes can also have fatal results. One of the biggest overall advances we can make in any safety-critical occupation would be to simply acknowledge that we’re all human and having limitations or making mistakes does not make you a bad person.

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May 16, 2018 2:58 pm
Reply to  sjdunham

The biggest medical problem is lawyers.

May 16, 2018 1:50 pm

Great article. On robotic surgery there is one company MZOR which has actually performed clinical trials to compare outcomes and proven very useful. But this is for spine surgery where it is more a planning device and guidance system to improve the precision of screw and implant placing vs a remote scalpel like davinci.

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