Sunday, 25 August 2013



Guest Blog by
Dr. Soumyadeep Bhaumik MBBS 
GP, Independent Researcher and Medical Correspondent
In 1921 Czech playwright Kapel Clark introduced the concept of robots (and in the process coined the term robot too) in his science fiction epic Rossum’s Universal Robots. Domin, the lead character of the play describes the future of robots as, “all work will be done by living machines. Everybody will be free from worry and liberated from the degradation of labour. Everybody will live only to perfect himself.” Ever since then robots have captured the imagination as well as the reality of humans. Robots are used nowadays in specific, precise, speedier and often hazardous work in domains ranging from industries to research to warfare. The entry and progression of robots however has been comparatively slower in the field of medicine.1

Robotic surgery is a new and emerging field that has taken the medical and particularly the surgical community by storm. Robotic surgery is a technique which in the simplest term can be described as a surgeon performing surgery using a computer that remotely controls very small instruments attached to a robot with multiple arms.

History of Surgical robots:

The background of development of robotic surgery is inherently intertwined with the development of minimally invasive surgery (MIS). MIS has various advantages like smaller incisions, lesser infection, shorter hospital stays, quicker discharge from hospital, decreased pain, better cosmesis, and better postoperative immune function2-4  An inherent problem with current laparoscopic equipment is the loss of haptic feedback (force and tactile), natural hand-eye coordination and dexterity1. Moreover laparoscopic instruments have restricted degrees of motion (usually 4) whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization (which is essentially two-dimensional). Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult 5. Most surgeons harped over these limitations and argued the supremacy of traditional surgeries but biomedical engineers collaborated with a handful of surgeons and developed the Puma-650 which was first used in precise neurosurgical biopsies2 and then in Trans-urethral resection of prostate (TURP)6. Robotic surgery gained rapid strides with the development of the PROBOT, ROBODOC, NeuroMate, PAKY-RCM, AcuBot and AESOP 1,7.The da Vinci Surgical System ultimately made the robotic surgical system popular globally. More than 1752 da Vinci systems are already installed in across 44 countries of the world.7

Pros and cons:

Robotic surgery promises to overcome the traditional obstacles of surgery1. They have better geometric accuracy, remain stable and do not get tired, can scale motion and offer more degrees of freedom than the human hand. They are precise and can access spaces or areas which a human hand cannot--thus making micro-anastomoses possible. Unlike humans, robots are not susceptible to radiation/infection or fatigue. Robots eliminate the fulcrum effect and also physiological tremors of the surgeon. Having fewer surgeons in the operating room and allowing doctors the ability to operate on a patient long-distance (tele-surgery) would also lower the cost of healthcare in the long term.7 More over because the surgical cuts are essentially smaller it provides all benefits of MIS, albeit in a greater dimension.

The prime disadvantage as of now with robotic surgery is not technology (which is bound to improve further in the future) but the costs involved. Robotic systems cost a whooping US $ 1 million to procure and recurring costs of $100,000/year. Such huge sums mean a lot if viewed in the light of public health measures in resource-poor developing and underdeveloped nations. Other concerns that have been raised are the requirement of extra staff to operate, steep learning curve and it’s yet to be proven cost-benefit ratio. A major cause of concern is the fact that robots do lack the capacity to earn the trust implicitly assumed in a surgeon-patient relationship8.What would be the psychological state of the patient peri/post operatively when he knows that his body parts is being handled by a machine made of ‘tins and oils’ ? What if the robot malfunctions? What if it is fed with the data for a wrong patient or for that matter even a wrong surgery? Who will be to blame in case something goes wrong?

What the future holds?

In spite of the fact that robotic surgery is fast spreading globally it is important to note that it is still in its infancy. The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, vision beyond the magnified eye, robot accessibility with a reduction of entry ports and miniaturizing the slave robot.7 In the near future robotic systems are expected to integrate various other technologies and modalities that are currently being used in the operating room. Efforts are already on to relay touch sensations from the robots to the surgeon and develop better suture less anastomoses7. Diagnostic modalities like USG, CT scan and MRI will soon be merged with robotic surgical equipments and guide the surgeon in better dissection and pathology identification. Nano-robots too are being developed across the world. Surgical training is also expected to radically change with robotic systems being used to rehearse procedures before doctors actually operate on a patient. Eventually tele-robotics will develop thereby enabling super-speciality surgeons to operate at inaccessible rural location without them being physically present in the operation theatre.

Evaluation of its safety, efficacy and long term effects vide randomised controlled trials is the need of the hour. Efforts to bring down costs should be specifically attempted. Unlike in industries or warfare clinical judgement is way too complex process which takes into account various factors beyond the operation table. The patient's socio-economic background, physico-intellectual status, his aspirations from life, emotional state, and cultural factors are issues which are taken onto account by the surgeon. Owing to the very nascent stage in which artificial Intelligence is currently the view that the automation age in robotic surgery has arrived and " it’s only a matter of time when it will run our lives for us” 8 is but a vision of the very distant future.

Soumyadeep Bhaumik is a blogger and his blog Caffeinated Works & Random Musings is one of the largest healthcare blogs in India

You can get in touch with him via



  1. Lanfranco AR, Castellanos AE,Desai JP,Meyers WC.Robotic surgery: a current perspective. Ann Surg 2004;239:14-21
  2. Kim VB, Chapman WH, Albrecht RJ, et al. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using DaVinci. Surg Laparosc Endosc Percutan Tech 2002;12:34–40.
  3. Fuchs KH. Minimally invasive surgery. Endoscopy 2002;34:154–159.
  4. Allendorf JD, Bessler M, Whelan RL, Trokel M, Laird DA, Terry MB et al. Postoperative immune function varies inversely with the degree of surgical trauma in a murine model.. Surg Endosc 1997;11:427–430
  5. Prasad SM, Ducko CT, Stephenson ER, Chambers CE, Damiano RJ Jr. Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up.Ann Surg. 2001;233:725–732.
  6. Davies B. A review of robotics in surgery. Proc Inst Mech Eng.2000;214:129–140.
  7. Wedmid A,Llukani E, Lee DI. Future perspectives in robotic surgery. Brit J Urol Int ;108:1028-1036( Avalilable online
  8. Nath NC.Robotics –the future of surgery. J Ind Med Assoc 2011;109:12-13

Wednesday, 7 August 2013

Don Berwick Report

Don Berwick NHS patient safety report - will it work?
It will. Though there is a blind spot to watch out. 

A blog from a particular perspective

Don Berwick report 'A promise to learn, a commitment to act, improving the safety of patients in England' has been published ( There is all round praise which is well deserved. The entire report is full of gems of wisdom. As a practising clinicians who also values work life balance, I have still managed to fast read the report, I will read it again in detail. As a student of improvement science I am sure I will learn a lot from the report. I am a fan of Don Berwick, I have heard him speak a number of times and every time I am not only moved but I always come away with great learning. It was one of the cherished moments in my professional life when I shook his hand at the Forum in London in April 2013 and he walked with me to personally introduced me to Sir Brian Jarman.

Don's report is pretty comprehensive as expected, I hope the report will be effective.

The Blind Spot
My problem with the report is not the content, my problem is with the membership of the advisory group. It is elementary in leadership that while what is said does matter, how it is said and who said it really matters more. Why do you think football celebrities endorse non-sports products?

The committee was happy that they were independent.

The advisory group was made up of 17 persons whose expertise is unquestionable. 4 of them were Americans from the Boston-Harvard area; with 3 of the 4 Americans from the same organisation. 12 out of 17 were non-NHS, the 13th was NHS Scotland. No Europeans. No one else from the US aside or instead of this close knit group.

9 of the 17 were women - finally it looks like we are recognising that the half the real world is indeed made up of a gender who are not male, well done. 

17 out of 17 seem to be white. 

Don Berwick is no stranger to England, he is no stranger to inclusive leadership. Don was obviously so dedicated to answering the questions put to him that his human limitations prevented him from recognising that in London when he walks the streets 50% are foreigners, 40% are Black and Minority Ethnic. If Don entered any hospital he may have noticed that about 40% of doctors are from BME origins and in London nearly 40% of healthcare staff are of BME origin and about 10% of this country are from BME backgrounds. Don's report speaks about adequate staffing. Where do you think that comes from? We are hearing reports of urgent recruitment of rota fodder to deal with the A&E staffing crises from countries like India, Don and his committee would recognise Indians are part of the BME group.

The Quality Chasm and Leadership Deficit

Who speaks to whom matters. Constituencies matter. Don is now a politician, he will do well to remember that his country's president won his office on the black vote (though certainly not exclusively on the black vote). If Don looked and did not find an person who has some expertise in quality and safety who also happened to be non-white he should have mentioned that a part of the system failure that he talks about.

The report talks about culture and fear. Amongst the most afraid in day to day clinical practice are BME doctors who face a higher rate of referral to their regulator; they are also thought to have higher rate and higher intensity of sanctions by their regulator. BME doctors also face extraordinarily adverse pass rate in their specialist examinations, unlike in Don's country.

It is not as though the committee did not have a BME connection. It did have a most profound and tragic BME connection. Lisa Richard Everton, a patients' representative on the committee lost her husband Paul Everton due to a lethal overdose at Heartlands. Paul Everton was black. Don would know that in our much revered NHS BME's get poorer health outcomes.

I was actually hoping to have interactions, debates or arguments on the technical aspects of improvement and patient safety issues with Don; I am sure I will in the near future. Instead I am talking about leadership, culture, inclusivity and race. On my initial reading, the report excels and succeeds at the theoretical and technical aspects where the content experts lead by example. The report fails in its operational aspects especially in the context of what the manpower constituency might recognise, mirror and reflect, the report and its committee fails by example

The inability to include or cope with a real mix of normal people is the biggest wall that prevents our already good NHS from achieving even higher standards. A different committee with some persons who have BME style thinking (as opposed to just simply being from a BME origin) in it would not have made any difference in the content of the report, I suspect it might have made a difference in the sincerity and speed of adoption. I am not a race warrior, this blog is not about race, regular readers of this blog would already know that. This blog is about contextual leadership which in essential for success in healthcare.

I remain a fan of Don Berwick, I do not write this in protest or complaint. I write this due to a genuine concern that Don, a person whom I admire and his recommendations should not fail. I write out of a genuine desire that the NHS should cross the quality chasm by overcoming the massive leadership deficit that it faces.

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PS: I recommend the report. It is up to us, normal NHS staff to make sure that we take this report to the front line and deliver it there to benefit our patients.

Friday, 2 August 2013

Skin in the Game


Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (; apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

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