Saturday, March 22, 2014

Misericordia, the surgeons want to be cool!

"Fashion is something barbarous, for it produces innovation without reason and imitation without benefit." -- George Santayana

My brother had a radical retropubertal resection of his prostate to treat aggressive prostate cancer. Due to the relationship we have, I could not have offered him any advice. If I had, it would have been ignored or operated in reverse. My opinion of his opinion of my opinions is not relevant here. The point is that I had told our intermediary, our father, that I hoped he would not get the surgery done by a DaVinci surgical robot. He did.

My dislike of the surgical robot was based on reading on the benefits of robotic vs. manual surgery. So far, the story of the robotic assistants is mixed. There has been no clinical advantage in outcomes for using robotic suites thusfar. The robot surgeries have a much higher incidence of surgical complications, though.

Additionally, I was against the idea because of how much of a fashion there is for them. When "everyone" is in favor of a brand new treatment, and the old treatment did not have noticeable deficiencies, then cui bono? Pro Publica has been watching the corporation behind the two robot prostate surgeons pretty carefully and has documented several instances of dangerous, unethical, and shady practices. Essentially, the companies that make the robots are investing in getting their surgical suites bought and used. They are also investing in medical research and ensuring that the report on whether the robots are clinically worthwhile points the right way.

As a patient, it turns out that the best bet is to go with a surgeon manually performing the surgery, if she or he has many repetitions. The robotic suites are responsible for more accidental injury than traditional surgery. However, the robotic suites discharge patients to home quickly. A patient who has a robotic surgery goes home quickly. This may give a better clinical outcome in the sense that such a patient is not exposed to hospital pathogens. However, the real benefit of the robotic surgery is to the health insurance company and, at least theoretically, the hospital administration, as both benefit from getting the patient out of the hospital bed as quickly as possible, whatever the surgical outcome.

When I was in graduate school, I was fortunately unfortunate enough to have to work full time and to do that work in a biochem lab. There, I worked with people developing bench science into a medicine, and the things had to be researched against and with everything. I was aware that any university researcher would investigate an agent every which way, so when the first Cox-2 inhibitors appeared on the market and advertised that they were good for patients taking Coumadin, I asked the local School of Pharmacy to check into the studies on patients on Warfarin. Two weeks later, they got back to me and said, "There aren't any." "What do you mean." "There aren't any." "Does that sound screwy to you?" "Yes. I wouldn't take the medicine, if I were you, and we're going to have to investigate this further." It was eighteen months later that enough people had died for the Vioxx scandal to begin.

"MBA culture" is notoriously slimey and wicked. It's the whole, "If the law lets us do it, then we have to do it" mindset. It's the mindset that leads to doing anything for this quarter's profits, even if it means destroying the productive capacity. MBA culture has been running the pharmaceuticals since 1990. Aside from a few wild-eyed hippie start ups, it runs medical device makers, too.

There are surgical fashions and fads. This fact alone ought to make every human who depends upon blood and oxygen freak out (i.e. everyone but Dick Cheney).

You only realize the perniciousness of surgical fashions and medical fads when they've passed. Where I live now, it is automatic that every hyperthyroid patient will have a thyroidectomy. It's automatic. Personally, I think that's barbarism, since there are good ways of suppressing thyroxine without hacking away at a fairly small organ and thereby making a person dependent, for life, on daily purchases of Synthroid. Oh, it's easy to say, "They have no endocrinologists in the turnip fields where you live, so let 'em get to zero thyroid function and replace physiologically," but that is admitting that "Paying every month to a pharmaceutical company" is a way of life. (Hyperthyroid patients can go into remission.) Similarly, every inguinal hernia here gets the mesh. Good old mesh. Nothing bad ever happens with mesh. Every atherosclerotic gets a stent. (Re-occlusion is less common now than it used to be, I admit, but the rates of reliance on stents is unaffected by this. It was the fashion here. No bypasses: stents.)

Whenever there is a fad or fashion in medicine, the question is who is making the decision? Usually, it's the health insuring group. They, in turn, make it for all patients, and not just their own.

Yesterday, I was at a used book store, and I mentioned that I had just had a lumbar radiofrequency ablation of nerves getting pinched by spinal arthritis. The proprietress told me about her husband. You see his problem was really that one of his legs was longer than the other.

Remember that one?

That was a scam that went around in the late 1980's and early 1990's. Faith healers and quacks alike used the gag. Put the patient in a chair, hold up his legs at a very slight angle to his body (coinciding with dominant leg/hand), and one leg will be "longer" than the other.

"He used to go to ______, where he'd get these inserts for his shoes that would let him walk right, and he'd keep them until he'd wear 'em out, and then he'd go get more. But _____ isn't in business anymore, and when he went to the orthopedist, they didn't want to do that!"

She was unhappy with the orthopedic surgeons who didn't want to feed him more rubber heels.

"He went to his chiropracter to be sure it wasn't an alignment issue."

So, because the fellow went to an orthopedic surgeon, you can guess what happened next. The surgeon wanted to surgically repair the herniated disks. Two surgeries, much pain, and the patient is still convinced that it was all a matter of walking "wrong" and needing special soles.

For my part, I just had nerves killed. There was no promise of making anything better except pain. I have arthritis in my spine and cannot take any anti-inflammatory drugs. However, commercials are airing now for all the people who don't take Warfarin but do take blood thinners to take a new pill instead.

If "everyone" is having something, someone is wanting it to be that way. Make sure you know who it is, why it is, and that you agree completely.


Anonymous said...

4/6 : Happy birthday, Mister G.


The Geogre said...

Thank you. It was one from the center of indifference. It did not bother me, one way or the other.