Forbes has a new article by Peter Ubel, “Doctors Can’t Be Trusted To Tell Patients Whether They Should Receive Robotic Surgery,” that discusses the results of a study of robotic prostate surgery. The results were unfortunate but not surprising: when robotic prostatectomy is available at a hospital, doctors are more likely to recommend it and to describe it favorably.
In the study, the medical researchers recorded 252 appointments at four Veterans Affairs medical centers, then coded the physicians’ descriptions of robotic surgery. At hospitals where the robotic surgery was not available, doctors said robotic surgery was worse than traditional surgery about 10 percent of the time, then said robotic surgery was equal to traditional surgery about as often (around 45%) as they said robotic surgery was better (also around 45%). At hospitals where robotic surgery was available, the doctors almost never (under 5%) said robotic surgery was worse than traditional surgery, and they infrequently (30%) said robotic surgery was the same. Instead, they said robotic surgery was better nearly two-thirds of the time.
That’s a big problem, given that “shared decision making” is supposed to be “the pinnacle of patient-centered care.” A patient needs to be deeply involved in healthcare decisions when there is more than one reasonable option, and where different options could produce different outcomes for – and different harms to – for the patient.
Ubel reaches a fair conclusion about the results, but I don’t think it’s the only conclusion:
I do not think physicians are willfully misleading patients about the pros and cons of robotic surgery. Instead, I think most physicians believe the robot is better (in the right hands) but when it is unavailable, doctors try to reassure patients that they will still receive state-of-the-art care. For example, one patient expressed anger that the robot was not available at his VA Hospital: “you see, that’s what’s so stupid about the VA!” The physician tried to assuage his concerns: “If you look at long-term outcomes related to cancer and cancer recurrence,” the surgeon said, “there has really been no difference. That’s why the VA system has not really invested in the robot.”
Ubel may be right — but this interpretation raises a bigger question.
There’s really no benefit at all to using the robot. Studies have repeatedly shown that. For example, a 2010 article in the medical journal Reviews in Urology found that traditional prostatectomy was still “the gold standard:”
Aside from reducing the amount of blood loss, current data suggest that the most significant outcomes (cure, continence, and potency) are no better with laparoscopic radical prostatectomy or robotic-assisted laparoscopic radical prostatectomy than with conventional open radical prostatectomy. Therefore, in experienced hands, open radical prostatectomy remains the gold standard procedure.
A 2015 article in the Canadian Urological Association Journal similarly found that, when it came to health-related quality of life, the benefits of robot-assisted radical prostatectomy compared to open prostatectomy “did not meet pre-defined thresholds of clinical significance.”
If traditional open prostatectomy is “the gold standard,” and the benefits of robotic-assisted prostatectomy are still unproven, why, then, are doctors so quick to say robotic surgery is superior? Even at hospitals where robotic surgery is not an option, doctors are just as prone to say robotic surgery is better as they are to say it is the same, a conclusion that just isn’t backed by the medical research. Worse, at hospitals where robotic surgery is an option, patients are given erroneous information about the benefits of robotic surgery nearly two-thirds of the time!
Personally, I think this is an example of “framing bias.” Robotic surgery has been marketed so heavily, and has been pushed so strongly by hospitals trying to justify the cost, that doctors have trouble looking at robotic surgery objectively. Instead of seeing robotic surgery as just another tool, one that might have some advantages and disadvantages but which hasn’t been proven as a better treatment, doctors see robotic surgery as a novel, cutting-edge approach that just hasn’t had enough studies done on it yet. Even though years of research has been performed, doctors keep believing that robotic surgery is on the verge of being proven as a superior way of performing operations.
Truth is, robotic surgery no better in the hands of an expert, experienced surgeon, and it may be worse if it encourages less-experienced or less-gifted surgeons to attempt procedures they would not perform the traditional way.